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Objectives: To identify the cooperation of authors, countries, institutions and explore the hot spots regarding research of renal cell carcinoma with venous tumor thrombus. Methods: Relevant articles were obtained from the Web of Science Core database (WoSC) from 1999 to 2024. CiteSpace was used to perform the analysis and visualization of scientific productivity and emerging trends. Network maps were generated to evaluate the collaborations between different authors, countries, institutions, and keywords. Results: A total of 2180 related articles were identified. We observed an increased enthusiasm in related fields during the past two decades. The USA dominated the field in all countries, and the University of Miami was the core institution. Ciancio G might have a significant influence with more publications and co-citations. Current research hotspots in this field mainly included thrombectomy, tyrosine kinase inhibitors, immune checkpoint inhibitors, vena cava inferior, and microvascular invasion. Thrombectomy complications, thrombectomy survival outcome, and preoperative neoadjuvant immunotherapy represented the frontiers of research in this field, undergoing an explosive phase. Conclusion: This is the first bibliometric study that comprehensively visualize the research trends and status of RCC with VTT. We hope that this work will provide new ideas for advancing the scientific research and clinical application.
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Bibliometría , Carcinoma de Células Renales , Neoplasias Renales , Humanos , Carcinoma de Células Renales/patología , Carcinoma de Células Renales/terapia , Neoplasias Renales/patología , Neoplasias Renales/terapia , Neoplasias Renales/cirugía , Trombosis de la Vena/patología , Trombosis de la Vena/cirugía , Trombectomía/métodosRESUMEN
BACKGROUND: Intravenous thrombolysis is a standard treatment of acute ischemic stroke. The efficacy and safety of combining intravenous thrombolysis with argatroban (an anticoagulant agent) or eptifibatide (an antiplatelet agent) are unclear. METHODS: We conducted a phase 3, three-group, adaptive, single-blind, randomized, controlled clinical trial at 57 sites in the United States. Patients with acute ischemic stroke who had received intravenous thrombolysis within 3 hours after symptom onset were assigned to receive intravenous argatroban, eptifibatide, or placebo within 75 minutes after the initiation of thrombolysis. The primary efficacy outcome, the utility-weighted 90-day modified Rankin scale score (range, 0 to 10, with higher scores reflecting better outcomes), was assessed by means of centralized adjudication. The primary safety outcome was symptomatic intracranial hemorrhage within 36 hours after randomization. RESULTS: A total of 514 patients were assigned to receive argatroban (59 patients), eptifibatide (227 patients), or placebo (228 patients). All the patients received intravenous thrombolysis (70% received alteplase, and 30% received tenecteplase), and 225 patients (44%) underwent endovascular thrombectomy. At 90 days, the mean (±SD) utility-weighted modified Rankin scale scores were 5.2±3.7 with argatroban, 6.3±3.2 with eptifibatide, and 6.8±3.0 with placebo. The posterior probability that argatroban was better than placebo was 0.002 (posterior mean difference in utility-weighted modified Rankin scale score, -1.51±0.51) and that eptifibatide was better than placebo was 0.041 (posterior mean difference, -0.50±0.29). The incidence of symptomatic intracranial hemorrhage was similar in the three groups (4% with argatroban, 3% with eptifibatide, and 2% with placebo). Mortality at 90 days was higher in the argatroban group (24%) and the eptifibatide group (12%) than in the placebo group (8%). CONCLUSIONS: In patients with acute ischemic stroke treated with intravenous thrombolysis within 3 hours after symptom onset, adjunctive treatment with intravenous argatroban or eptifibatide did not reduce poststroke disability and was associated with increased mortality. (Funded by the National Institute of Neurological Disorders and Stroke; MOST ClinicalTrials.gov number, NCT03735979.).
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Eptifibatida , Hemorragias Intracraneales , Accidente Cerebrovascular Isquémico , Péptidos , Ácidos Pipecólicos , Sulfonamidas , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Arginina/administración & dosificación , Arginina/efectos adversos , Arginina/análogos & derivados , Quimioterapia Combinada/efectos adversos , Quimioterapia Combinada/métodos , Eptifibatida/administración & dosificación , Eptifibatida/efectos adversos , Fibrinolíticos/administración & dosificación , Fibrinolíticos/efectos adversos , Infusiones Intravenosas , Hemorragias Intracraneales/inducido químicamente , Hemorragias Intracraneales/epidemiología , Accidente Cerebrovascular Isquémico/mortalidad , Accidente Cerebrovascular Isquémico/terapia , Péptidos/administración & dosificación , Péptidos/efectos adversos , Péptidos/uso terapéutico , Ácidos Pipecólicos/administración & dosificación , Ácidos Pipecólicos/efectos adversos , Inhibidores de Agregación Plaquetaria/administración & dosificación , Inhibidores de Agregación Plaquetaria/efectos adversos , Método Simple Ciego , Sulfonamidas/administración & dosificación , Sulfonamidas/efectos adversos , Terapia Trombolítica/efectos adversos , Terapia Combinada/efectos adversos , Terapia Combinada/métodos , Trombectomía/efectos adversos , Trombectomía/métodos , Resultado del Tratamiento , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Incidencia , AdultoRESUMEN
We present two clinical cases of successful endovascular treatment of proximal deep vein thrombosis following May-Thurner syndrome. In the first case, 2-day regional catheter thrombolysis, percutaneous mechanical thrombectomy and venous stenting were required to restore hemodynamics in the left lower limb. In the second case, regional catheter thrombolysis continued for 3 days with subsequent thrombotic mass lysis. However, iliac vein was severely narrowed that required venous stenting. Long-term results were favorable in both cases. Venous outflow has become almost normal after endovascular treatment. The patients' ability to work has been restored.
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Procedimientos Endovasculares , Vena Ilíaca , Síndrome de May-Thurner , Stents , Trombectomía , Trombosis de la Vena , Humanos , Síndrome de May-Thurner/complicaciones , Síndrome de May-Thurner/terapia , Síndrome de May-Thurner/diagnóstico , Síndrome de May-Thurner/cirugía , Trombosis de la Vena/etiología , Trombosis de la Vena/terapia , Trombosis de la Vena/cirugía , Trombosis de la Vena/diagnóstico , Procedimientos Endovasculares/métodos , Resultado del Tratamiento , Vena Ilíaca/cirugía , Trombectomía/métodos , Femenino , Masculino , Terapia Trombolítica/métodos , Persona de Mediana Edad , Adulto , Extremidad Inferior/irrigación sanguíneaRESUMEN
SOURCE CITATION: Costalat V, Jovin TG, Albucher JF, et al; LASTE Trial Investigators. Trial of thrombectomy for stroke with a large infarct of unrestricted size. N Engl J Med. 2024;390:1677-1689. 38718358.
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Procedimientos Endovasculares , Accidente Cerebrovascular Isquémico , Trombectomía , Humanos , Trombectomía/métodos , Accidente Cerebrovascular Isquémico/cirugía , Procedimientos Endovasculares/métodos , Masculino , Femenino , Anciano , Resultado del TratamientoRESUMEN
Pulmonary embolism is a manifestation of venous thromboembolic disease, characterized by thrombus formation within the pulmonary arteries. Symptoms and clinical signs are numerous and nonspecific. Diagnosis relies on medical imaging (thoracic CT angiography or ventilation/perfusion scintigraphy). This disease requires prompt management to reduce morbidity and mortality. Treatment strategies include anticoagulation, systemic or catheter-guided thrombolysis, mechanical thrombectomy or surgery. In our institution, we have a multidisciplinary team, called PERT (Pulmonary Embolism Response Team), responsible for guiding the management of pulmonary embolism and for facilitating the access to those emerging endovascular techniques.
L'embolie pulmonaire est une manifestation de la maladie thromboembolique veineuse, caractérisée par la formation d'un ou plusieurs thrombi au sein des artères pulmonaires. Les symptômes et signes cliniques sont nombreux et non spécifiques. Le diagnostic repose sur l'imagerie médicale (angioscanner thoracique ou scintigraphie de ventilation/perfusion). Cette pathologie nécessite une prise en charge rapide pour en réduire la morbidité et la mortalité. Les stratégies de traitement incluent l'anticoagulation, la thrombolyse systémique ou guidée par cathéter, la thrombectomie mécanique ou la chirurgie. Au sein de notre institution, nous disposons d'une équipe multidisciplinaire, appelée PERT («Pulmonary Embolism Response Team¼), chargée d'orienter la prise en charge thérapeutique de l'embolie pulmonaire et de faciliter le recours aux nouvelles techniques endovasculaires disponibles.
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Embolia Pulmonar , Humanos , Embolia Pulmonar/terapia , Embolia Pulmonar/diagnóstico , Trombectomía/métodos , Terapia Trombolítica/métodos , Masculino , Anticoagulantes/uso terapéutico , FemeninoRESUMEN
OBJECTIVE: Although mechanical thrombectomy (MT) is primarily performed via transfemoral access (TFA), transradial access (TRA) is a potential alternative in older patients or those with tortuous vessels. However, the small radial artery diameter restricts the use of large-bore balloon guides and aspiration catheters, a limitation that may be overcome using the sheathless technique. Thus, we aimed to explore the feasibility, efficacy, and safety of sheathless TRA-MT as a first-line treatment approach for acute ischemic stroke. METHODS: This single-center retrospective case series included patients who underwent TRA-MT as first-line treatment between September 2020 and June 2023. Per our MT protocol, TRA was not the first-line approach in cases of left anterior circulation lesions with a type 3 aortic arch. We evaluated treatment effectiveness based on the successful recanalization rate, puncture-to-recanalization time, and modified first-pass effect; access route effectiveness based on the puncture-to-first-pass time and switch-to-TFA rate; and procedure safety based on procedure-related and severe puncture site complications. RESULTS: Sheathless 8-F guide catheters were used in 68â¯% and large-bore aspiration catheters in 70â¯% of the procedures. Successful recanalization was achieved in 98â¯% of the patients, with a modified first-pass effect in 54â¯% of them. The median puncture-to-first-pass and puncture-to-recanalization times were 20.5 and 33â¯min, respectively. The rate of procedure-related complications was low (4â¯%), with no severe puncture site complications. CONCLUSION: Sheathless TRA-MT enabled the use of large-bore guide and aspiration catheters, providing a swift approach to the target and satisfactory outcomes, and might be an effective first-line treatment for acute ischemic stroke.
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Estudios de Factibilidad , Accidente Cerebrovascular Isquémico , Arteria Radial , Trombectomía , Humanos , Masculino , Anciano , Femenino , Arteria Radial/cirugía , Estudios Retrospectivos , Persona de Mediana Edad , Resultado del Tratamiento , Accidente Cerebrovascular Isquémico/cirugía , Accidente Cerebrovascular Isquémico/terapia , Trombectomía/métodos , Trombectomía/instrumentación , Anciano de 80 o más AñosRESUMEN
PURPOSE: Evaluate the outcomes of patients undergoing large-bore aspiration thrombectomy for the treatment of pulmonary embolism at a large university medical center. MATERIALS AND METHODS: All patients treated for pulmonary embolism with the FlowTriever System (Inari Medical, Irvine, CA) between September 2019 and January 2023 were retrospectively analyzed. The primary safety and effectiveness outcomes included 7- and 30-day all-cause mortality, major bleeding, procedure-associated clinical decompensation, pulmonary vascular or cardiac injury, and pulmonary artery pressure reduction. Additional outcomes included technical success (completing thrombectomy with the device as intended), changes in hemodynamics and supplemental oxygen requirements, and postprocedural intensive care unit stay. RESULTS: A total of 286 patients were identified. The mean age was 60.5 years, and 90.9% of patients presented with intermediate-risk pulmonary embolism. Technical success was achieved in 96.9% (n = 277) of cases. The average reduction in mean pulmonary arterial pressure was 6.8 mmHg, from 28.7 ± 9.0 to 21.9 ± 8.0 mmHg (p < 0.0001). Two major bleeds (0.7%), 2 pulmonary vascular injuries (0.7%), and 4 (1.4%) procedure-associated decompensations were reported, but no device-related deaths occurred. The mean post-procedure intensive care unit stay was 2.0 ± 4.1 days, and 49.3% of patients had no postprocedural intensive care unit admittance. The overall 7-day and 30-day all-cause mortality rates were 2.4% and 6.7%, respectively, with a 30-day pulmonary embolism-related mortality rate of 3.5%. CONCLUSION: This non-industry-sponsored single-center analysis of large-bore aspiration thrombectomy in a large population corroborates the findings of other studies and confirms that this approach is safe and effective for the treatment high- and intermediate-risk pulmonary embolism. LEVEL OF EVIDENCE IV: Retrospective observational study.
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Embolia Pulmonar , Trombectomía , Humanos , Embolia Pulmonar/terapia , Embolia Pulmonar/cirugía , Estudios Retrospectivos , Masculino , Femenino , Persona de Mediana Edad , Trombectomía/métodos , Anciano , Resultado del Tratamiento , Adulto , Anciano de 80 o más AñosRESUMEN
Background The combination of intravenous thrombolysis (IVT) with mechanical thrombectomy (MT) may have clinical benefits for patients with medium vessel occlusion. Purpose To examine whether MT combined with IVT is associated with different outcomes than MT alone in patients with acute ischemic stroke (AIS) and medium vessel occlusion. Materials and Methods This retrospective study included consecutive adult patients with AIS and medium vessel occlusion treated with MT or MT with IVT at 37 academic centers in North America, Asia, and Europe. Data were collected from September 2017 to July 2021. Propensity score matching was performed to reduce confounding. Univariable and multivariable logistic regression analyses were performed to test the association between the addition of IVT treatment and different functional and safety outcomes. Results After propensity score matching, 670 patients (median age, 75 years [IQR, 64-82 years]; 356 female) were included in the analysis; 335 underwent MT alone and 335 underwent MT with IVT. Median onset to puncture (350 vs 210 minutes, P < .001) and onset to recanalization (397 vs 273 minutes, P < .001) times were higher in the MT group than the MT with IVT group, respectively. In the univariable regression analysis, the addition of IVT was associated with higher odds of a modified Rankin Scale (mRS) score 0-2 (odds ratio [OR], 1.44; 95% CI: 1.06, 1.96; P = .019); however, this association was not observed in the multivariable analysis (OR, 1.37; 95% CI: 0.99, 1.89; P = .054). In the multivariable analysis, the addition of IVT also showed no evidence of an association with the odds of first-pass effect (OR, 1.27; 95% CI: 0.9, 1.79; P = .17), Thrombolysis in Cerebral Infarction grades 2b-3 (OR, 1.64; 95% CI: 0.99, 2.73; P = .055), mRS scores 0-1 (OR, 1.27; 95% CI: 0.91, 1.76; P = .16), mortality (OR, 0.78; 95% CI: 0.49, 1.24; P = .29), or intracranial hemorrhage (OR, 1.25; 95% CI: 0.88, 1.76; P = .21). Conclusion Adjunctive IVT may not provide benefit to MT in patients with AIS caused by distal and medium vessel occlusion. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Wojak in this issue.
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Accidente Cerebrovascular Isquémico , Trombectomía , Terapia Trombolítica , Humanos , Femenino , Masculino , Anciano , Estudios Retrospectivos , Trombectomía/métodos , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/cirugía , Accidente Cerebrovascular Isquémico/terapia , Persona de Mediana Edad , Anciano de 80 o más Años , Terapia Trombolítica/métodos , Terapia Combinada , Resultado del Tratamiento , Fibrinolíticos/uso terapéutico , Fibrinolíticos/administración & dosificación , Puntaje de PropensiónRESUMEN
RATIONALE: Alcoholic cardiomyopathy (ACM) is associated with various cardiac complications, but the development of isolated right atrial (RA) thrombus without deep vein thrombosis is rare and presents diagnostic challenges. PATIENT CONCERNS: A 53-year-old Hispanic male presented with shortness of breath, chills, cough, bilateral lower extremity edema, and distended abdomen. DIAGNOSES: The patient was diagnosed with ACM, liver cirrhosis, and a large RA thrombus. Initial transthoracic echocardiography showed severe left ventricular systolic dysfunction but failed to detect the RA mass. Subsequent computed tomography scan and transesophageal echocardiography revealed a large oval mass in the RA, measuring 40 mm × 22 mm × 18 mm. INTERVENTIONS: The patient received guideline-directed medical therapy for heart failure and anticoagulation with enoxaparin. He underwent cardiac catheterization for mechanical thrombectomy, which was minimally successful. OUTCOMES: The patient's condition was managed with the prescribed interventions. Regular follow-up was planned to assess thrombolysis. LESSONS: RA thrombosis is an uncommon complication of ACM. A multimodal imaging approach, with a low threshold for transesophageal echocardiography, is crucial in evaluating patients with ACM who present with cardiac complications. This approach enables accurate diagnosis and management of rare conditions like isolated RA thrombosis.
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Cardiomiopatía Alcohólica , Atrios Cardíacos , Trombosis , Humanos , Masculino , Persona de Mediana Edad , Trombosis/etiología , Trombosis/diagnóstico por imagen , Atrios Cardíacos/diagnóstico por imagen , Cardiomiopatía Alcohólica/complicaciones , Cardiomiopatía Alcohólica/diagnóstico , Ecocardiografía Transesofágica/métodos , Cardiopatías/etiología , Cardiopatías/diagnóstico , Cateterismo Cardíaco/métodos , Trombectomía/métodosRESUMEN
BACKGROUND: Endovascular therapy for acute ischemic stroke has been shown to be highly effective in selected patients. However, the ideal criteria for patient selection are still debated. It is well known that collateral flow is an important factor, but the assessment is often subjective and time-consuming. Relative cerebral blood volume (rCBV) is a putative indicator of collateral capacity and can be quickly and easily determined by automated quantitative analysis. We investigated the relationship between rCBV of the affected region and clinical outcome in patients with acute ischemic stroke after endovascular therapy. METHODS: We conducted a retrospective study on consecutive patients between January 2017 and May 2019. Patients with acute ischemic stroke of the anterior circulation who underwent imaging including computed tomography perfusion and were treated with mechanical thrombectomy (MT) were eligible for inclusion. rCBV was calculated automatically with RAPID software by dividing the average cerebral blood volume (CBV) of the affected region (time-to-maximum (Tmax) > 6 s) by the CBV of the unaffected contralateral side. The primary outcome was determined by the modified Rankin Scale (mRS) after 90 days. Good clinical outcome was defined as mRS ≤ 2. We compared means, performed mono- and multivariate logistical regression and calculated a receiver operating characteristic (ROC)-analysis to determine the ideal cutoff value to predict clinical outcomes. RESULTS: 155 patients were enrolled in this study. 66 patients (42.58%) had good clinical outcomes. Higher rCBV was associated with good clinical outcome (p < 0.001), even after adjustment for the patients' status according to mRS and National Institute of Health Stroke Scale (NIHSS) age and Alberta stroke program early computed tomography score (ASPECTS) at baseline (p = 0.006). ROC-analysis revealed 0.650 (confidence interval: 0.616-0.778) as the optimal cutoff value. CONCLUSION: Higher rCBV at baseline is associated with good clinical long-term outcomes in patients with acute ischemic stroke treated by MT. In this study we provide the biggest collective so far that gives evidence that rCBV can be a valuable tool to identify patients who might benefit from MT and are able give a threshold to help to offer patients MT in borderline cases.
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Volumen Sanguíneo Cerebral , Accidente Cerebrovascular Isquémico , Humanos , Masculino , Femenino , Estudios Retrospectivos , Volumen Sanguíneo Cerebral/fisiología , Anciano , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/terapia , Accidente Cerebrovascular Isquémico/fisiopatología , Persona de Mediana Edad , Resultado del Tratamiento , Anciano de 80 o más Años , Procedimientos Endovasculares/métodos , Trombectomía/métodos , Estudios de CohortesRESUMEN
INTRODUCTION: The Appalachia region of North America is known to have significant health disparities, specifically, worse risk factors and outcomes for stroke. Appalachians are more likely to have comorbidities related to stroke, such as diabetes, obesity, and tobacco use, and are often less likely to have stroke interventions, such as mechanical thrombectomy (MT), for emergent large vessel occlusion (ELVO). As our Comprehensive Stroke Center directly serves stroke subjects from both Appalachian and non-Appalachian areas, inflammatory proteomic biomarkers were identified associated with stroke outcomes specific to subjects residing in Appalachia. METHODS: There were 81 subjects that met inclusion criteria for this study. These subjects underwent MT for ELVO, and carotid arterial blood samples acquired at time of intervention were sent for proteomic analysis. Samples were processed in accordance with the Blood And Clot Thrombectomy Registry And Collaboration (BACTRAC; clinicaltrials.gov; NCT03153683). Statistical analyses were utilized to examine whether relationships between protein expression and outcomes differed by Appalachian status for functional (NIH Stroke Scale; NIHSS and Modified Rankin Score; mRS), and cognitive outcomes (Montreal Cognitive Assessment; MoCA). RESULTS: No significant differences were found in demographic data or co-morbidities when comparing Appalachian to non-Appalachian subjects. However, time from stroke onset to treatment (last known normal) was significantly longer and edema volume significantly higher in patients from Appalachia. Further, when comparing Appalachian to non-Appalachian subjects, there were significant unadjusted differences in the NIHSS functional outcome. A comprehensive analysis of 184 proteins from Olink proteomic (92 Cardiometabolic and 92 Inflammation panels) showed that the association between protein expression outcomes significantly differed by Appalachian status for seven proteins for the NIHSS, two proteins for the MoCA, and three for the mRS. CONCLUSION: Our study utilizes an ELVO tissue bank and registry to investigate the intracranial/intravascular proteomic environment occurring at the time of thrombectomy. We found that patients presenting from Appalachian areas have different levels of proteomic expression at the time of MT when compared to patients presenting from non-Appalachian areas. These proteins differentially relate to stroke outcome and could be used as prognostic biomarkers, or as targets for novel therapies. The identification of a disparate proteomic response in Appalachian patients provides initial insight to the biological basis for health disparity. Nevertheless, further investigations through community-based studies are imperative to elucidate the underlying causes of this differential response.
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Accidente Cerebrovascular Isquémico , Proteómica , Trombectomía , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Región de los Apalaches/epidemiología , Accidente Cerebrovascular Isquémico/sangre , Accidente Cerebrovascular Isquémico/cirugía , Trombectomía/tendencias , Trombectomía/métodos , Resultado del TratamientoAsunto(s)
Procedimientos Endovasculares , Accidente Cerebrovascular Isquémico , Trombectomía , Humanos , Trombectomía/métodos , Accidente Cerebrovascular Isquémico/cirugía , Procedimientos Endovasculares/métodos , Anciano , Masculino , Femenino , Factores de Edad , Anciano de 80 o más Años , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND: The ideal blood pressure (BP) target in patients who undergo endovascular thrombectomy (EVT) with successful reperfusion is uncertain. Observational studies show that elevated BP during this period is associated with a higher risk of intracranial hemorrhage (ICH) and worse clinical outcomes. Several randomized controlled trials (RCTs) have explored whether intensive BP lowering improves clinical outcomes in these patients. AIMS: This review aims to summarize the recent RCTs that compare intensive and conventional BP management strategies following EVT and discuss the innovative directions to improve. RESULT: The recently published RCTs failed to demonstrate the benefit of intensive BP control on the functional outcome and decreasing the risk of ICH. The complex mechanism in cerebral blood flow regulation and the inappropriate BP range chosen in RCTs may be the reasons behind the inconsistent results between observational studies and RCTs. Individualized BP management, reducing BP variability, and multi-stage BP management should be paid more attention in future exploration. CONCLUSION: Intensive BP target did not improve clinical outcomes after successful EVT as compared with a conventional BP target. Further research is required to identify the optimal BP management strategy after reperfusion.
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Presión Sanguínea , Procedimientos Endovasculares , Ensayos Clínicos Controlados Aleatorios como Asunto , Trombectomía , Humanos , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Trombectomía/métodos , Procedimientos Endovasculares/métodos , Presión Sanguínea/fisiología , Presión Sanguínea/efectos de los fármacosRESUMEN
Importance: Randomized clinical trials have demonstrated the efficacy and safety of endovascular thrombectomy for acute ischemic stroke with large infarct. Patients older than 80 years with large infarct are commonly encountered in clinical practice but underrepresented in randomized clinical trials. Objective: To provide an age-based analysis of functional outcomes in endovascular thrombectomy for acute ischemic strokes with large infarct. Design, Setting, and Participants: This retrospective multicenter cohort study included patients from the German Stroke Registry who received endovascular thrombectomy for acute ischemic stroke with large infarct at 1 of 25 German stroke centers between May 2015 and December 2021. Patients with acute ischemic stroke due to anterior circulation large vessel occlusion and large infarct were included. Large infarct was defined as an Alberta Stroke Program Early Computed Tomography Score of 0 to 5. Patients were subdivided by age to evaluate its association with functional outcomes. Exposure: Age. Main Outcomes and Measures: Primary outcomes were independent ambulation (90-day modified Rankin Scale score of 0-3) and mortality (90-day modified Rankin Scale score of 6). Results: A total of 408 patients with large infarct were included (217 women [53.2%]; median [IQR] age, 75 [64-83] years). The rate of independent ambulation decreased from 56.4% in patients aged 60 years and younger (44 of 78 patients) to 15.1% in patients older than 80 years (19 of 126 patients) (P < .001), while mortality increased from 15.4% (12 patients) to 64.3% (81 patients) (P < .001). Being older than 80 years was associated with lower rates of independent ambulation (adjusted odds ratio [aOR], 0.44; 95% CI, 0.23-0.82; P = .01) and higher mortality (aOR, 2.75; 95% CI, 1.61-4.72; P < .001). A final modified Thrombolysis in Cerebral Infarction grade of 2b or 3 was associated with higher rates of independent ambulation (aOR, 4.95; 95% CI, 2.14-11.43; P < .001), independent of age and without significant interaction (aOR, 0.69; 95% CI, 0.35-1.34; P = .27). Conclusions and Relevance: In this cohort study of patients with acute ischemic stroke and large infarct, age was associated with functional outcomes. Patients older than 80 years had poor prognosis with high mortality but with sizeable differences depending on additional baseline and treatment characteristics. While it does not seem justified to apply a fixed upper age limit for endovascular thrombectomy, these results could assist clinicians in making informed treatment decisions in older patients with large ischemic stroke.
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Procedimientos Endovasculares , Accidente Cerebrovascular Isquémico , Trombectomía , Humanos , Anciano , Femenino , Trombectomía/métodos , Masculino , Anciano de 80 o más Años , Procedimientos Endovasculares/métodos , Accidente Cerebrovascular Isquémico/cirugía , Accidente Cerebrovascular Isquémico/mortalidad , Accidente Cerebrovascular Isquémico/terapia , Estudios Retrospectivos , Persona de Mediana Edad , Factores de Edad , Resultado del Tratamiento , Sistema de Registros , Alemania/epidemiologíaRESUMEN
OBJECTIVES: This study aimed to assess the predictive performance of radiomics derived from computed tomography (CT) images of thrombus regions in predicting the risk of intracranial hemorrhage (ICH) following endovascular thrombectomy (EVT). MATERIALS AND METHODS: This retrospective multicenter study included 336 patients who underwent admission CT and EVT for acute anterior-circulation large vessel occlusion between December 2018 and December 2023. Follow-up imaging was performed 24 h post-procedure to evaluate the occurrence of ICH. 230 patients from centers A and B were randomly allocated into training and test groups in a 7:3 ratio, while the remaining 106 patients from center C comprised the validation cohort. Radiologists manually segmenting the thrombus on CT images, and the perithrombus region was defined by expanding the initial region of interest (ROI). A total of 428 radiomics features were extracted from both intrathrombus and perithrombus regions on CT images. The Mann-Whitney U test was used for feature selection, and least absolute shrinkage and selection operator (LASSO) regression was employed for model development, followed by validation using a 5-fold cross-validation approach. Model performance was assessed using the area under the curve (AUC) of the receiver operating characteristic (ROC). RESULTS: Among the eligible patients, 128 (38.1 %) experienced ICH after EVT. The combined model exhibited superior performance in the training cohort (AUC: 0.913, 95 % CI: 0.861-0.965), test cohort (AUC: 0.868, 95 % CI: 0.775-0.962), and validation cohort (AUC: 0.850, 95 % CI: 0.768-0.912). Notably, in the validation group, both the perithrombus and combined models demonstrated higher predictive accuracy compared to the intrathrombus model (0.837 vs. 0.684, p = 0.02; AUC: 0.850 vs. 0.684, p = 0.01). CONCLUSIONS: Radiomics features derived from the perithrombus region significantly enhance the prediction of ICH after EVT, providing valuable insights for optimizing post-procedural clinical decisions. CLINICAL RELEVANCE STATEMENT: This study highlights the importance of radiomics extracted from intrathrombus and perithrombus region in predicting intracranial hemorrhagefollowing endovascular thrombectomy, which can aid in improving patient outcomes.
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Procedimientos Endovasculares , Hemorragias Intracraneales , Radiómica , Trombectomía , Trombosis , Tomografía Computarizada por Rayos X , Humanos , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Hemorragias Intracraneales/diagnóstico por imagen , Hemorragias Intracraneales/etiología , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Medición de Riesgo/métodos , Trombectomía/efectos adversos , Trombectomía/métodos , Trombosis/diagnóstico por imagen , Trombosis/cirugía , Tomografía Computarizada por Rayos X/métodosRESUMEN
BACKGROUND AND OBJECTIVES: Acute ischemic stroke patients with a large vessel occlusion (LVO) who present to a primary stroke center (PSC) often require transfer to a comprehensive stroke center (CSC) for thrombectomy. Not much is known about specific characteristics at the PSC that are associated with infarct growth during transfer. Gaining more insight into these features could aid future trials with cytoprotective agents targeted at slowing infarct growth. We aimed to identify baseline clinical and imaging characteristics that are associated with fast infarct growth rate (IGR) during interhospital transfer. METHODS: We included patients from the CT Perfusion to Predict Response to Recanalization in Ischemic Stroke Project, a prospective multicenter study. Patients with an anterior circulation LVO who were transferred from a PSC to a CSC for consideration of thrombectomy were eligible if imaging criteria were fulfilled. A CT perfusion (CTP) needed to be obtained at the PSC followed by an MRI at the CSC, before consideration of thrombectomy. The interhospital IGR was defined as the difference between the infarct volumes on MRI and CTP, divided by the time between the scans. Multivariable logistic regression was used to determine characteristics associated with fast IGR (≥5 mL/h). RESULTS: A total of 183 patients with a median age of 74 years (interquartile range 61-82), of whom 99 (54%) were male and 82 (45%) were fast progressors, were included. At baseline, fast progressors had a higher NIH Stroke Scale score (median 16 vs 13), lower cerebral blood volume index (median 0.80 vs 0.89), more commonly poor collaterals on CT angiography (35% vs 13%), higher hypoperfusion intensity ratios (HIRs) (median 0.51 vs 0.34), and larger core volumes (median 11.80 mL vs 0.00 mL). In multivariable analysis, higher HIR (adjusted odds ratio [aOR] for every 0.10 increase 1.32 [95% CI 1.10-1.59]) and larger core volume (aOR for every 10 mL increase 1.54 [95% CI 1.20-2.11]) remained independently associated with fast IGR. DISCUSSION: Fast infarct growth during interhospital transfer of acute stroke patients is associated with imaging markers of poor collaterals on baseline imaging. These markers are promising targets for patient selection in cytoprotective trials aimed at reducing interhospital infarct growth.
Asunto(s)
Accidente Cerebrovascular Isquémico , Transferencia de Pacientes , Trombectomía , Humanos , Masculino , Anciano , Femenino , Estudios Prospectivos , Trombectomía/métodos , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/cirugía , Persona de Mediana Edad , Anciano de 80 o más Años , Imagen por Resonancia Magnética , Tomografía Computarizada por Rayos XRESUMEN
INTRODUCTION: Poststroke hyperglycaemia is an independent risk factor for poorer outcomes in patients treated with mechanical thrombectomy (MT) and is associated with a lower probability of functional recovery and higher mortality at 3 months. This study aims to evaluate the association between glucose levels during cerebral reperfusion with MT and functional recovery at 3 months, measured by subcutaneous continuous glucose monitoring (CGM) devices. METHODS: This prospective observational study aims to recruit 100 patients with ischaemic stroke and large anterior circulation vessel occlusion, in whom MT is indicated. CGM will be performed using a Freestyle Libre ProIQ device (FSL-CGM, Abbott Diabetes Care, Alameda, California, USA), which will be implanted on admission to the emergency department, to monitor glucose levels before, during and after reperfusion. The study's primary endpoint will be the functional status at 3 months, as measured by the dichotomised modified Rankin Scale (0-2 indicating good recovery and 3-6 indicating dependency or death). We will analyse expression profiles of microRNA (miRNA) at the time of reperfusion and 24 hours later, as potential biomarkers of ischaemic-reperfusion injury. The most promising miRNAs include miR-100, miR-29b, miR-339, miR-15a and miR-424. All patients will undergo treatment according to current international recommendations and local protocols for the treatment of stroke, including intravenous thrombolysis if indicated. ETHICS AND DISSEMINATION: This study (protocol V.1.1, dated 29 October 2021, code 6017) has been approved by the Clinical Research Ethics Committee of La Paz University Hospital (Madrid, Spain) and has been registered in ClinicalTrials.gov (NCT05871502). Study results will be disseminated through peer-reviewed publications in Open Access format and at conference presentations. TRIAL REGISTRATION NUMBER: NCT05871502.
Asunto(s)
Glucemia , Accidente Cerebrovascular Isquémico , Daño por Reperfusión , Trombectomía , Humanos , Estudios Prospectivos , Accidente Cerebrovascular Isquémico/terapia , Accidente Cerebrovascular Isquémico/cirugía , Trombectomía/métodos , Daño por Reperfusión/terapia , Glucemia/metabolismo , Glucemia/análisis , Hiperglucemia/complicaciones , Estudios Observacionales como Asunto , Masculino , MicroARNs , Recuperación de la Función , FemeninoRESUMEN
PURPOSE OF REVIEW: Renal Cell Carcinoma (RCC) with invasion into the inferior vena cava (IVC) is a rare and mortal condition. Patients with RCC have an average life expectancy of no more than six months, thus requiring an aggressive surgical approach. We analyze the outcomes of patients that underwent surgery at a single medical institution. RECENT FINDINGS: The analysis of recent series of successful treatment with radical nephrectomy and IVC thrombectomy shows a 5 year survival from 45 to 69%. We found in the analyzed series that the success of the treatment in these patients depends on the resection of the renal tumor and venous thrombectomy. We found that at our medical institution nephrectomy and IVC thrombectomy with primary repair have no intraoperative mortality and no pulmonary embolism. Nephrectomy and thrombectomy of IVC is a reliable approach for patients with advance RCC.