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Huang, Hsuan-Li. "Pre-EVT Evaluation, Intra-EVT Guidance, Post-EVT Follow-Up of Duplex Ultrasound for Low Extremity Arterial Disease (LEAD)." Ultrasound in Medicine & Biology 43 (2017): S59. http://dx.doi.org/10.1016/j.ultrasmedbio.2017.08.1147.
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Honig, Asaf, Hen Hallevi, Naaem Simaan, Tzvika Sacagiu, Estelle Seyman, Andrei Filioglo, Moshe J. Gomori, et al. "Safety and Efficacy of Intravenous Alteplase before Endovascular Thrombectomy: A Pooled Analysis with Focus on the Elderly." Journal of Clinical Medicine 11, no. 13 (June 26, 2022): 3681. http://dx.doi.org/10.3390/jcm11133681.
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Current guidelines advocate intravenous thrombolysis (IVT) prior to endovascular thrombectomy (EVT) for all patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). We evaluated outcomes with and without IVT pretreatment. Our institutional protocols allow AIS patients presenting early (<4 h from onset or last seen normal) who have an Alberta Stroke Program Early CT Score (ASPECTS) ≥6 to undergo EVT without IVT pretreatment if the endovascular team is in the hospital (direct EVT). Rates of recanalization and hemorrhagic transformation (HT) and neurological outcomes were retrospectively compared in consecutive patients undergoing IVT+EVT vs. direct EVT with subanalyses in those ≥80 years and ≥85 years. In the overall cohort (IVT+EVT = 147, direct EVT = 162), and in subsets of patients ≥80 years (IVT+EVT = 51, direct EVT = 50) and ≥85 years (IVT+EVT = 19, direct EVT = 32), the IVT+EVT cohort and the direct EVT group had similar baseline characteristics, underwent EVT after a comparable interval from symptom onset, and reached similar rates of target vessel recanalization. No differences were observed in the HT frequency, or in disability at discharge or after 90 days. Patients receiving direct EVT underwent more stenting of the carotid artery due to stenosis during the EVT procedure (22% vs. 6%, p = 0.001). Direct EVT and IVT+EVT had comparable neurological outcomes in the overall cohort and in the subgroups of patients ≥80 and ≥85 years, suggesting that direct EVT should be considered in patients with an elevated risk for HT.
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Purrucker, Jan C., Peter A. Ringleb, Fatih Seker, Arne Potreck, Simon Nagel, Silvia Schönenberger, Anne Berberich, Ulf Neuberger, Markus Möhlenbruch, and Charlotte Weyland. "Leaving the day behind: endovascular therapy beyond 24 h in acute stroke of the anterior and posterior circulation." Therapeutic Advances in Neurological Disorders 15 (January 2022): 175628642211010. http://dx.doi.org/10.1177/17562864221101083.
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Background: There is little evidence of endovascular therapy (EVT) being performed in acute ischemic stroke beyond 24 h, and that evidence is limited to anterior circulation stroke. Objective: To extend evidence of efficacy and safety of EVT after more than 24 h in both anterior and posterior circulation stroke. Methods: Local, prospectively collected registries were screened for patients with acute ischemic stroke and large-vessel occlusion who had received either EVT > 24 h after last-seen-well but <24 h after symptom recognition (EVT>24LSW) or EVT > 24 h since first (definitive) symptom recognition (EVT>24DEF). Patients treated <24 h served as a group for comparison. Favorable outcome was defined as modified Rankin scale (mRS) 0–2 or return to prestroke mRS at 3 months. Results: Between January 2014 and August 2021, N = 2347 were treated with EVT at our comprehensive stroke center, of whom n = 43 met the inclusion criteria (EVT>24LSW, n = 16, EVT>24DEF, n = 27). EVT>24LSW patients were treated at a median of 28.7 h [interquartile range (IQR) = 27.3–32.8] after last-seen-well and 7.3 h (IQR = 2.8–14.3) after symptom recognition; EVT>24DEF patients were treated 52.5 h (IQR = 26.5–94.2) after first symptoms. Favorable outcome was achieved by 23.3% (10/43) in the EVT > 24 compared with 39.4% (886/2250) in the EVT < 24 group ( p = 0.04). Bleeding rates were similar across groups. Mortality was also similar [EVT > 24, 27.9% (12/43) versus EVT < 24, 25.7% (584/2264), p = 0.727; posterior circulation, EVT > 24, 41.7% (5/12) versus EVT < 24, 36.5% (92/252) p = 0.764]. Conclusion: In selected patients, EVT seems effective and safe beyond 24 h for both anterior and posterior circulation stroke.
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Tilburgs, Tamara, Angela Crespo, Anita van der Zwan, Ashley Moffett, and Jack Strominger. "Human HLA-G+ extravillous trophoblasts: immune activating cells that interact with decidual leucocytes (MUC2P.921)." Journal of Immunology 194, no. 1_Supplement (May 1, 2015): 65.4. http://dx.doi.org/10.4049/jimmunol.194.supp.65.4.
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Abstract Invading HLA-G+ extravillous trophoblasts (EVT) are believed to play a key role in the prevention of a maternal immune attack on foreign fetal tissues. EVT are difficult to study due to their low frequency and lack of proliferative capacity. Here highly purified HLA-G+ EVT and HLA-G- villous trophoblast (VT) were isolated. Culture on fibronectin increased HLA-G expression on EVT but differentiation from VT into EVT was not observed. Moreover microarray analysis demonstrated that VT and EVT have more than 4200 differentially expressed genes. Functional gene set enrichment analysis (GSEA) revealed a striking immune activating potential for EVT that is absent in VT. Co-culture of HLA-G+ EVT with sample matched decidual NK, macrophages, CD4+ and CD8+ T cells were established and demonstrated interactions of all leukocyte types with EVT. Interaction of EVT with CD4+ T cells resulted in increased proportion of CD4+CD25hiFOXP3+ Tregs and increased FOXP3 protein level in these cells. However, EVT did not enhance cytokine secretion in dNK whereas stimulation of dNK using mitogens or classical NK targets confirmed the distinct cytokine profiles of dNK and pNK. Thus EVT are specialized cells with an immune activating profile whose properties are not imitated by HLA-G expressing cell lines. Careful validation of EVT-leukocyte interactions using primary HLA-G+ EVT needs to be carried out to understand the unique contribution of EVT to the decidual immune response in human pregnancy.
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Sarraj, Amrou, Sean Savitz, Deep Pujara, Haris Kamal, Kirsten Carroll, Faris Shaker, Sujan Reddy, et al. "Endovascular Thrombectomy for Acute Ischemic Strokes." Stroke 51, no. 4 (April 2020): 1207–17. http://dx.doi.org/10.1161/strokeaha.120.028850.
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Background and Purpose— Timely access to endovascular thrombectomy (EVT) centers is vital for best acute ischemic stroke outcomes. Methods— US stroke-treating centers were mapped utilizing geo-mapping and stratified into non-EVT or EVT if they reported ≥1 acute ischemic stroke thrombectomy code in 2017 to Center for Medicare and Medicaid Services. Direct EVT-access, defined as the population with the closest facility being an EVT-center, was calculated from validated trauma-models adapted for stroke. Current 15- and 30-minute access were described nationwide and at state-level with emphasis on 4 states (TX, NY, CA, IL). Two optimization models were utilized. Model-A used a greedy algorithm to capture the largest population with direct access when flipping 10% and 20% non-EVT to EVT-centers to maximize access. Model-B used bypassing methodology to directly transport patients to the nearest EVT centers if the drive-time difference from the geo-centroid to hospital was within 15 minutes from the geo-centroid to the closest non-EVT center. Results— Of 1941 stroke-centers, 713 (37%) were EVT. Approximately 61 million (19.8%) Americans have direct EVT access within 15 minutes while 95 million (30.9%) within 30 minutes. There were 65 (43%) EVT centers in TX with 22% of the population currently within 15-minute access. Flipping 10% hospitals with top population density improved access to 30.8%, while bypassing resulted in 45.5% having direct access to EVT centers. Similar results were found in NY (current, 20.9%; flipping, 34.7%; bypassing, 50.4%), CA (current, 25.5%; flipping, 37.3%; bypassing, 53.9%), and IL (current, 15.3%; flipping, 21.9%; bypassing, 34.6%). Nationwide, the current direct access within 15 minutes of 19.8% increased by 7.5% by flipping the top 10% non-EVT to EVT-capable in all states. Bypassing non-EVT centers by 15 minutes resulted in a 16.7% gain in coverage. Conclusions— EVT-access within 15 minutes is limited to less than one-fifth of the US population. Optimization methodologies that increase EVT centers or bypass non-EVT to the closest EVT center both showed enhanced access. Results varied by states based on the population size and density. However, bypass showed more potential for maximizing direct EVT-access. National and state efforts should focus on identifying gaps and tailoring solutions to improve EVT-access.
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Hassan, Ameer E., Hari Kotta, Leeroy Garza, Laurie Preston, Wondwossen Tekle, Amrou Sarraj, and Adnan I. Qureshi. "Pre-thrombectomy intravenous thrombolytics are associated with increased hospital bills without improved outcomes compared with mechanical thrombectomy alone." Journal of NeuroInterventional Surgery 11, no. 12 (May 18, 2019): 1187–90. http://dx.doi.org/10.1136/neurintsurg-2019-014837.
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ObjectiveTo investigate whether significant differences exist in hospital bills and patient outcomes between patients who undergo endovascular thrombectomy (EVT) alone and those who undergo EVT with pretreatment intravenous tissue plasminogen activator (IV tPA).MethodsWe retrospectively grouped patients in an EVT database into those who underwent EVT alone and those who underwent EVT with pretreatment IV tPA (EVT+IV tPA). Hospital encounter charges (obtained via the hospital’s charge capture process), final patient bills (ie, negotiated final bills as per insurance/Medicare rates), demographic information, existing comorbidities, admission and discharge National Institutes of Health Stroke Scale (NIHSS) score, and functional independence data (modified Rankin Scale score 0–2) were collected. Univariate and multivariate statistical analyses were performed.ResultsOf a total of 254 patients, 96 (37.8%) underwent EVT+IV tPA. Median NIHSS score at admission was significantly higher in the EVT+IV tPA group than in the EVT group (p=0.006). After adjusting for NIHSS admission score, patient bills and encounter charges in the EVT+IV tPA group were still found to be $3861.64 (95% CI $658.84 to $7064.45, p=0.02) and $158 071.29 (95% CI $134 641.50 to $181 501.08, p < 0.001) greater than in the EVT only group respectively. The EVT+IV tPA group had a higher complication rate of intracranial hemorrhage (ICH) (p=0.005). The EVT and EVT+IV tPA groups did not differ significantly in median discharge NIHSS score (p=0.56), functional independence rate at 90 days (p=0.96), or average length of hospital stay (p=0.21).ConclusionPatients treated with EVT+IV tPA have greater hospital encounter charges and final hospital bills as well as higher rates of ICH than patients who undergo treatment with EVT only.
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Kim, Byungjun, Byung Moon Kim, Oh Young Bang, Jang-Hyun Baek, Ji Hoe Heo, Hyo Suk Nam, Young Dae Kim, et al. "Carotid Artery Stenting and Intracranial Thrombectomy for Tandem Cervical and Intracranial Artery Occlusions." Neurosurgery 86, no. 2 (March 8, 2019): 213–20. http://dx.doi.org/10.1093/neuros/nyz026.
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Abstract BACKGROUND It remains controversial whether carotid artery stenting (CAS) is needed in cases of tandem cervical internal carotid artery occlusion (cICAO) and intracranial large vessel occlusion (LVO). OBJECTIVE To investigate the efficacy and safety of CAS in combination with endovascular thrombectomy (CAS-EVT) in cICAO-LVO patients and to compare its outcomes with those of EVT without CAS (EVT-alone). METHODS We identified all patients who underwent EVT for tandem cICAO-LVO from the prospectively maintained registries of 17 stroke centers. Patients were classified into 2 groups: CAS-EVT and EVT-alone. Clinical characteristics and procedural and clinical outcomes were compared between 2 groups. We tested whether CAS-EVT strategy was independently associated with recanalization success. RESULTS Of the 955 patients who underwent EVT, 75 patients (7.9%) had cICAO-LVO. Fifty-six patients underwent CAS-EVT (74.6%), and the remaining 19 patients underwent EVT-alone (25.4%). The recanalization (94.6% vs 63.2%, P = .002) and good outcome rates (64.3% vs 26.3%, P = .007) were significantly higher in the CAS-EVT than in the EVT-alone. Mortality was significantly lower in the CAS-EVT (7.1% vs 21.6%, P = .014). There was no significant difference in the rate of symptomatic intracranial hemorrhage between 2 groups (10.7 vs 15.8%; P = .684) and according to the use of glycoprotein IIb/IIIa inhibitor (10.0% vs 12.3%; P = .999) or antiplatelet medications (10.2% vs 18.8%; P = .392). CAS-EVT strategy remained independently associated with recanalization success (odds ratio: 24.844; 95% confidence interval: 1.445-427.187). CONCLUSION CAS-EVT strategy seemed to be effective and safe in cases of tandem cICAO-LVO. CAS-EVT strategy was associated with recanalization success, resulting in better clinical outcome.
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Yang, Hua Yun. "Research on the Test Methods of Electronic Voltage Transformer under Complex Field Environment." Applied Mechanics and Materials 568-570 (June 2014): 478–82. http://dx.doi.org/10.4028/www.scientific.net/amm.568-570.478.
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EVT (electronic voltage transformer) is one of the key devices of the intelligent substation. This paper introduces the basic principles of EVT error tests. By analyzing the test environment of EVT with GIS structure, this paper establishes the high-voltage side equivalent circuit for the field EVT calibration methods and proposes to carry out field boost for the EVT with GIS structure, which could effectively improve the field calibration efficiency of EVT. Based on the research on the complex field environment of EVT, this paper puts forward the field test methods of EVT with AIS structure and the results show the effectiveness and correctness of this study.
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Paul, Samit, and Prateek Sharma. "Quantile forecasts using the Realized GARCH-EVT approach." Studies in Economics and Finance 35, no. 4 (October 1, 2018): 481–504. http://dx.doi.org/10.1108/sef-09-2016-0236.
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PurposeThis study aims to implement a novel approach of using the Realized generalized autoregressive conditional heteroskedasticity (GARCH) model within the conditional extreme value theory (EVT) framework to generate quantile forecasts. The Realized GARCH-EVT models are estimated with different realized volatility measures. The forecasting ability of the Realized GARCH-EVT models is compared with that of the standard GARCH-EVT models.Design/methodology/approachOne-step-ahead forecasts of Value-at-Risk (VaR) and expected shortfall (ES) for five European stock indices, using different two-stage GARCH-EVT models, are generated. The forecasting ability of the standard GARCH-EVT model and the asymmetric exponential GARCH (EGARCH)-EVT model is compared with that of the Realized GARCH-EVT model. Additionally, five realized volatility measures are used to test whether the choice of realized volatility measure affects the forecasting performance of the Realized GARCH-EVT model.FindingsIn terms of the out-of-sample comparisons, the Realized GARCH-EVT models generally outperform the standard GARCH-EVT and EGARCH-EVT models. However, the choice of the realized estimator does not affect the forecasting ability of the Realized GARCH-EVT model.Originality/valueIt is one of the earliest implementations of the two-stage Realized GARCH-EVT model for generating quantile forecasts. To the best of the authors’ knowledge, this is the first study that compares the performance of different realized estimators within Realized GARCH-EVT framework. In the context of high-frequency data-based forecasting studies, a sample period of around 11 years is reasonably large. More importantly, the data set has a cross-sectional dimension with multiple European stock indices, whereas most of the earlier studies are based on the US market.
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Wee, Chee-Keong, William McAuliffe, Constantine C. Phatouros, Timothy J. Phillips, David Blacker, Tejinder P. Singh, Ellen Baker, and Graeme J. Hankey. "Outcomes of Endovascular Thrombectomy with and without Thrombolysis for Acute Large Artery Ischaemic Stroke at a Tertiary Stroke Centre." Cerebrovascular Diseases Extra 7, no. 2 (May 2, 2017): 95–102. http://dx.doi.org/10.1159/000470855.
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Background and Purpose: Endovascular thrombectomy (EVT) improves the functional outcome when added to best medical therapy, including alteplase, in patients with acute ischaemic stroke secondary to large vessel occlusion (LVO) in the anterior circulation. However, the evidence for EVT in alteplase-ineligible patients is less compelling. It is also uncertain whether alteplase is necessary in patients with successful recanalization by EVT, as the treatment effect of EVT may be so powerful that bridging alteplase may not add to efficacy and may compromise safety by increasing bleeding risks. We aimed to survey the proportion of patients suitable for EVT who are alteplase-ineligible and to compare the safety and effectiveness of standard care of acute large artery ischaemic stroke by EVT plus thrombolysis with that of EVT alone in a tertiary hospital clinical stroke service. Methods: We performed a retrospective analysis of acute ischaemic stroke patients treated with EVT at our centre between October 2013 and April 2016, based on a registry with prospective and consecutive patient collection. Individual patient records were retrieved for review. Significant early neurological improvement was defined as a NIHSS score of 0–1, or a decrease from baseline of ≤8, at 24 h after stroke onset. Results: Fifty patients with acute ischaemic stroke secondary to LVO in the anterior circulation received EVT in this period, of whom 21 (42%) received concurrent alteplase and 29 (58%) EVT alone. The 2 groups had similar baseline characteristics and similar outcomes. Significant neurological improvement at 24 h occurred in 47.6% of the patients with EVT and bridging alteplase and in 51.7% of the patients with EVT alone (p = 0.774). Mortality during acute hospitalization was 20% for the bridging alteplase group versus 7.1% for EVT alone (p = 0.184). Intracranial haemorrhage rates were 14.3% for bridging alteplase versus 20.7% for EVT alone (p = 0.716). Local complications, groin haematoma (23.8 vs. 10.3%) and groin pseudoaneurysms (4.8 vs. 0%) (p = 0.170), were not significantly different. Conclusion: Our study highlights the relatively large proportion of patients suitable for EVT who have a contraindication to alteplase and raises the hypothesis that adding alteplase to successful EVT may not be necessary to optimize functional outcome. The results are consistent with observational data from other endovascular centres and support a randomised controlled trial of EVT versus EVT with bridging alteplase.
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Lee, Seong-Joon, Ji Man Hong, Jong S. Kim, and Jin Soo Lee. "Endovascular Treatment for Posterior Circulation Stroke: Ways to Maximize Therapeutic Efficacy." Journal of Stroke 24, no. 2 (May 31, 2022): 207–23. http://dx.doi.org/10.5853/jos.2022.00941.
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The efficacy of endovascular treatment (EVT) in patients with posterior circulation stroke has not been proven. Two recent randomized controlled trials failed to show improved functional outcomes after EVT for posterior circulation stroke (PC-EVT). However, promising results for two additional randomized controlled trials have also been presented at a recent conference. Studies have shown that patients undergoing PC-EVT had a higher rate of futile recanalization than those undergoing EVT for anterior circulation stroke. These findings call for further identification of prognostic factors beyond recanalization. The significance of baseline clinical severity, infarct volume, collaterals, time metrics, core-penumbra mismatch, and methods to accurately measure these parameters are discussed. Furthermore, their interplay on EVT outcomes and the potential to individualize patient selection for PC-EVT are reviewed. We also discuss technical considerations for improving the treatment efficacy of PC-EVT.
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Rodríguez-Pardo, Jorge, Nicolas Riera-López, Blanca Fuentes, María Alonso de Leciñana, Sergio Secades-García, Julia Álvarez-Fraga, Pablo Busca-Ostolaza, et al. "Prehospital selection of thrombectomy candidates beyond large vessel occlusion." Neurology 94, no. 8 (January 24, 2020): e851-e860. http://dx.doi.org/10.1212/wnl.0000000000008998.
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ObjectiveCurrent prehospital scales used to detect large vessel occlusion reveal very low endovascular thrombectomy (EVT) rates among selected patients. We developed a novel prehospital scale, the Madrid-Direct Referral to Endovascular Center (M-DIRECT), to identify EVT candidates for direct transfer to EVT-capable centers (EVT-Cs). The scale evaluated clinical examination, systolic blood pressure, and age. Since March 2017, patients closer to a stroke unit without EVT capabilities and an M-DIRECT positive score have been transferred to the nearest EVT-C. To test the performance of the scale-based routing protocol, we compared its outcomes with those of a simultaneous cohort of patients directly transferred to an EVT-C.MethodsIn this prospective observational study of consecutive patients with stroke code seen by emergency medical services, we compared diagnoses, treatments, and outcomes of patients who were closer to an EVT-C (mothership cohort) with those transferred according to the M-DIRECT score (M-DIRECT cohort).ResultsThe M-DIRECT cohort included 327 patients and the mothership cohort 214 patients. In the M-DIRECT cohort, 227 patients were negative and 100 were positive. Twenty-four (10.6%) patients required secondary transfer, leaving 124 (38%) patients from the M-DIRECT cohort admitted to an EVT-C. EVT rates were similar for patients with ischemic stroke in both cohorts (30.9% vs 31.5%). The M-DIRECT scale had 79% sensitivity, 82% specificity, and 53% positive predictive value for EVT. Recanalization and independence rates at 3 months did not differ between the cohorts.ConclusionsThe M-DIRECT scale was highly accurate for EVT, with treatment rates and outcomes similar to those of a mothership paradigm, thereby avoiding EVT-C overload with a low rate of secondary transfers.
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Changal, Khalid Hamid, Mubbasher Ameer Syed, Tawseef Dar, Muhammad Asif Mangi, and Mujeeb Abdul Sheikh. "Systematic Review and Proportional Meta-Analysis of Endarterectomy and Endovascular Therapy with Routine or Selective Stenting for Common Femoral Artery Atherosclerotic Disease." Journal of Interventional Cardiology 2019 (April 14, 2019): 1–12. http://dx.doi.org/10.1155/2019/1593401.
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Introduction. Common femoral endarterectomy (CFE) has been the therapy of choice for common femoral artery atherosclerotic disease (CFA-ASD). In the past, there was inhibition to treat CFA-ASD endovascularly with stents due to fear of stent fracture and compromise of future vascular access site. However, recent advances and new evidence suggest that CFA may no longer be a ‘stent-forbidden zone’. In the light of new evidence, we conducted a meta-analysis to determine the use of endovascular treatment for CFA-ASD and compare it with common femoral endarterectomy in the present era.Methods. Using certain MeSH terms we searched multiple databases for studies done on endovascular and surgical treatment of CFA-ASD in the last two decades. Inclusion criteria were randomized control trials, observational, prospective, or retrospective studies evaluating an endovascular treatment or CFE for CFA-ASD. For comparison, studies were grouped based on the treatment strategy used for CFA-ASD: endovascular treatment with selective stenting (EVT-SS), endovascular treatment with routine stenting (EVT-RS), or common femoral endarterectomy (CFE). Primary patency (PP), target lesion revascularization (TLR), and complications were the outcomes studied. We did proportional meta-analysis using a random-effect model due to heterogeneity among the included studies. If confidence intervals of two results do not overlap, then statistical significance is determined.Results. Twenty-eight studies met inclusion criteria (7 for EVT-RS, 8 for EVT-SS, and 13 for CFE). Total limbs involved were 2914 (306 in EVT-RS, 678 in EVT-SS, and 1930 in CFE). The pooled PP at 1 year was 84% (95% CI 75-92%) for EVT-RS, 78% (95% CI 69-85%) for EVT-SS, and 93% (95% CI 90-96%) for CFE. PP at maximum follow-up in EVT-RS was 83.7% (95% CI 74-91%) and in CFE group was 88.3% (95% CI 81-94%). The pooled target lesion revascularization (TLR) rate at one year was 8% (95% CI 4-13%) for EVT-RS, 19% (95% CI 14-23%) for EVT-SS, and 4.5% (95% CI 1-9%) for CFE. The pooled rate of local complications for EVT-RS was 5% (95% CI 2-10%), for EVT-SS was 7% (95% CI 3 to 12%), and CFE was 22% (95% CI 14-32%). Mortality at maximum follow-up in CFE group was 23.1% (95% CI 14-33%) and EVT-RS was 5.3% (95% CI 1-11%).Conclusion. EVT-RS has comparable one-year PP and TLR as CFE. CFE showed an advantage over EVT-SS for one-year PP. The complication rate is lower in EVT RS and EVT SS compared to CFE. At maximum follow-up, CFE and EVT-RS have similar PP but CFE has a higher mortality. These findings support EVT-RS as a management alternative for CFA-ASD.
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Paiva, P., L. A. Salamonsen, U. Manuelpillai, and E. Dimitriadis. "223. Interleukin-11 inhibits human trophoblast invasion via STAT-3 and not MAPK, indicating a likely role in the decidual restraint of trophoblast invasion during placentation." Reproduction, Fertility and Development 20, no. 9 (2008): 23. http://dx.doi.org/10.1071/srb08abs223.
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Successful pregnancy depends on the precise regulation of extravillous trophoblast (EVT) invasion into the uterine decidua, primarily by decidua-derived factors. In humans, during early pregnancy, interleukin (IL)-11 is maximally expressed in the decidua1, with its receptor, IL-11-receptor α (Rα) also identified on invasive EVT in vivo2. While a role for IL-11 in EVT migration has been established2, whether it also plays a role in regulating EVT invasion is unknown. We investigated whether IL-11 influences human EVT invasion and the signalling pathways and underlying mechanisms involved using the HTR-8/SVneo immortalised EVT cell-line and primary EVT as models for EVT. The effect of IL-11 on tyrosine phosphorylation (p) of signal transducer and activator of transcription (STAT)-3 was determined by Western Blot. EVT invasion was assessed using in vitro Matrigel invasion assays. To elucidate the mechanisms by which IL-11 may influence EVT invasion, matrix metalloproteinase (MMP) and urokinase plasminogen activator (uPA) activity were assessed by gelatin and plasminogen zymography / uPA activity assay respectively. Tissue inhibitor of MMPs (TIMPs)-1 and –2, plasminogen activator inhibitor (PAI)-1 and –2 and uPA receptor (uPAR) were assessed by ELISA whereas TIMP-3 was assessed by Western Blot. EVT adhesive properties and integrin expression were assessed by in vitro adhesion assays. IL-11 (100 ng/mL) significantly inhibited invasion of EVT cells by 40–60% (P < 0.001). This effect was abolished by inhibitors of STAT-3 but not of mitogen-activated protein kinase pathways. IL-11 (100 ng/mL) had no effect on MMP-2 and –9, TIMP 1–3, uPA, uPAR, PAI-1 and –2 in EVT conditioned media and / or cell lysates. IL-11 (100 ng/mL) also did not regulate EVT cell adhesion or integrin expression. These data demonstrate that IL-11 inhibits human EVT invasion via STAT-3 indicating an important role for IL-11 in the decidual restraint of EVT invasion during normal pregnancy. (1) Dimitriadis et al. (2003) Reprod Biol Endocrinol. 1, 34–38 (2) Paiva et al. (2007) Endocrinol. 148, 5566–72
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Shi, Xinwei, Guoqiang Zheng, Hao Liu, Jing Cao, Wanlu Liu, Yuqi Li, Fuyuan Qiao, Dongrui Deng, and Yuanyuan Wu. "Vascular endothelial growth factor C participates in regulation of maspin in extravillous trophoblast cell migration and invasion." Reproduction, Fertility and Development 31, no. 8 (2019): 1410. http://dx.doi.org/10.1071/rd18438.
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Mammary serine protease inhibitor (maspin; also known as serpin family B member 5 (SERPINB5)) plays a vital role in regulating the biological functions of extravillous trophoblast (EVT) cells, but the mechanism remains unclear. Vascular endothelial growth factor (VEGF) C is a signature angiogenic molecule expressed and secreted by first-trimester trophoblasts, and bioinformatics analyses has revealed upregulation of VEGFC in pre-eclampsia. The aim of this study was to explore whether maspin regulates EVT cells by regulating the expression of VEGFC. Reverse transcription–polymerase chain reaction and western blotting were used to investigate the effects of hypoxia on the expression of VEGFC in EVT cells. Cells were treated with recombinant (r) maspin and decitabine (to selectively inhibit DNA methyltransferases and then upregulate maspin gene expression), and the effects on VEGFC expression evaluated. In addition, the effects of rVEGFC on the biological functions of EVT cells invitro were evaluated using cell migration and invasion assays. Hypoxia increased the expression of VEGFC in EVT cells. rMaspin upregulated the expression of VEGFC in normoxic EVT cells, and downregulated the expression of VEGFC in hypoxic EVT cells at 24h. Decitabine increased VEGFC expression in normoxic EVT cells, but had no significant effect on VEGFC expression in hypoxic EVT cells. rVEGFC promoted the migration and invasion of normoxic EVT cells and inhibited the invasion of hypoxic EVT cells. These results suggest that VEGFC is involved in the regulation of maspin in EVT cell migration and invasion. However, other molecular mechanisms may be involved and require further investigation.
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Raza, Syed Ali, and Srikant Rangaraju. "Prognostic Scores for Large Vessel Occlusion Strokes." Neurology 97, no. 20 Supplement 2 (November 16, 2021): S79—S90. http://dx.doi.org/10.1212/wnl.0000000000012797.
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Purpose of the ReviewEndovascular thrombectomy (EVT) for large vessel occlusion strokes (LVOS) presents several treatment challenges. We provide a summary of existing tools for patient selection (pre-EVT tools) and for prognostication of long-term outcomes following reperfusion therapy (post-EVT tools).Recent FindingsRecently published randomized trials demonstrated superiority of EVT over medical therapy alone for LVOS. Uniform patient selection paradigms based on demographic, clinical, and radiographic variables are not completely standardized, leading to variability in patient selection for EVT for LVOS. Post-EVT, an accurate assessment of long-term prognosis is critical in the decision-making process.SummaryPrognostic scores can serve as useful adjuncts to facilitate clinical decision-making during early management of patients with ischemic stroke, particularly those with LVOS. The acute management of LVOS comprises rapid clinical assessment, triage, and cerebrovascular imaging, followed by evaluation for candidacy for thrombolysis and EVT. Pre-EVT prognostic tools that accurately predict the likelihood of benefit from EVT may guide reliable, efficient, and cost-effective patient selection. Following EVT, severe stroke deficits and subacute poststroke complications that portend a poor prognosis may warrant invasive therapies. Clinical decisions regarding these treatment options involve careful discussions between providers and patient families, and are also based on prognosis provided by the treating clinician. Reliable post-EVT prognostic tools can facilitate this by providing accurate and objective prognostic information. Several prognostic tools have been developed and validated in the literature, some of which may be applicable in the pre-EVT and post-EVT settings, although clinical utility and application varies. Validation in contemporary datasets as well as implementation and impact studies are needed before these scales can be used to guide clinical decisions for individual patients.
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Meyer, Alexander, Anne Schilling, Magdalena Kott, Ulrich Rother, Werner Lang, and Susanne Regus. "Open Versus Endovascular Revascularization of Below-Knee Arteries in Patients With End-Stage Renal Disease and Critical Limb Ischemia." Vascular and Endovascular Surgery 52, no. 8 (July 18, 2018): 613–20. http://dx.doi.org/10.1177/1538574418789036.
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Background: Evaluation of below-the-knee open revascularization (OR) versus endovascular revascularization (EVT) in patients with end-stage renal disease and critical limb ischemia (CLI) was performed. Patients and Methods: Seventy-seven dialysis patients with CLI and infrapopliteal involvement from 2007 to 2017 were included. Thirty-five patients received OR and 42 patients were treated with EVT. Survival, amputation-free survival (AFS) and wound-healing were evaluated. Furthermore, both groups were analyzed for differences as to anatomic (lesion length, runoff, pedal arch classification) and clinical (VSG risk score, WIfI score) characteristics. Results: Amputation-free survival (1-year AFS: OR 54.5% vs 47.6% in EVT, 2-year AFS OR 38.3% vs 23.9% EVT, P = .201) did not significantly differ between OR and EVT nor did the wound healing rate (29% OR vs 31% EVT, P = .532). Overall survival was noticeably poor (1-year survival: 66.7% in OR and 49% in EVT, 2-year survival OR 47.4% vs EVT 27.7%; P = .088); evaluation of peripheral runoff (Rutherford score 6.9 OR vs 7.1 EVT, P = .499) and pedal arch classification as well as WIfI or VSG risk score (9.8 OR vs 9.6 EVT, P = .673) could not detect significant differences as to both the groups. Treated median lesion length was significantly increased in OR patients (OR 26 cm vs EVT 7 cm, P < .001), whereas the incidence of major adverse cardiac events was higher in EVT patients (67% in EVT vs 40% OR, P = .023). Conclusion: OR and EVT showed comparable outcomes as to AFS and wound healing. Poor overall survival remains the determining factor in patients with ESRD having CLI. Both groups differ in terms of anatomic features as lesion length and severity of comorbidities; considering the comparable long-term outcomes, decision-making should be based on these premises; individually applied, each method can contribute to limb salvage, although the overall survival remains limited.
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Wiegers, Eveline J. A., Kars C. J. Compagne, Paula M. Janssen, Esmee Venema, Jaap W. Deckers, Wouter J. Schonewille, Jan Albert Vos, et al. "Path From Clinical Research to Implementation." Stroke 51, no. 7 (July 2020): 1941–50. http://dx.doi.org/10.1161/strokeaha.119.026731.
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Before 2015, endovascular treatment (EVT) for acute ischemic stroke was considered a promising treatment option. Based on limited evidence, it was performed in several dedicated stroke centers worldwide on selected patients. Since 2015, EVT for patients with intracranial large vessel occlusion has quickly been implemented as standard treatment in many countries worldwide, supported by the revised international guidelines based on solid evidence from multiple clinical trials. We describe the development in use of EVT in the Netherlands before, during, and after the pivotal EVT trials. We used data from all patients who were treated with EVT in the Netherlands from January 2002 until December 2018. We undertook a time-series analysis to examine trends in the use of EVT using Poisson regression analysis. Incidence rate ratios per year with 95% CIs were obtained to demonstrate the impact and implementation after the publication of the EVT trial results. We made regional observation plots, adjusted for stroke incidence, to assess the availability and use of the treatment in the country. In the buildup to the MR CLEAN (Multicenter Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands), a slow increase of EVT patients was observed, with 0.2% of all ischemic stroke patients receiving EVT. Before the trial results were formally announced, a statistically significant increase in EVT-treated patients per year was observed (incidence rate ratio, 1.72 [95% CI, 1.46–2.04]), and after the trial publication, an immediate steep increase was seen, followed by a more gradual increase (incidence rate ratio, 2.14 [95% CI, 1.77–2.59]). In 2018, the percentage of ischemic stroke patients receiving EVT increased to 5.8%. A well-developed infrastructure, a pragmatic approach toward the use of EVT in clinical practice, in combination with a strict adherence by the regulatory authorities to national evidence-based guidelines has led to successful implementation of EVT in the Netherlands. Ongoing efforts are directed at further increasing the proportion of stroke patients with EVT in all regions of the country.
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Li, Zhenhua, Yangang Zheng, Ahmed Abu-Siada, Mengyao Lu, Hongbin Li, and Yanchun Xu. "Online Evaluation for the Accuracy of Electronic Voltage Transformer Based on Recursive Principal Components Analysis." Energies 13, no. 21 (October 25, 2020): 5576. http://dx.doi.org/10.3390/en13215576.
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The electronic voltage transformer (EVT) has received much attention with the recent global trend to establish smart grids and digital substations. One of the main issues of the EVT is the deterioration of its performance with long-term operation which affects the control and protection systems it is employed for and hence the overall reliability of the power grids. This calls for the essential need for a reliable technique to regularly assess the accuracy of operating EVT in real-time. Unfortunately, traditional calibration methods cannot detect the incipient EVT performance change in real-time. As such, this paper presents a new online method to evaluate the accuracy of the EVT. In this regard, the Q-statistic is calculated based on the recursive principal components analysis (RPCA) using the output data of EVT to map up the changes of metering error on the electric–physics relationship. By employing the output data of the EVT along with the power grid characteristics, the performance of the EVT is evaluated without the need for a standard transformer, as per the current industry practice. Results show that the proposed method can assess the EVT with a 0.2 accuracy class.
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Ni, Weiyi, Wolfgang Kunz, Mayank Goyal, Yu Li Ng, Kelvin Tan, and Deidre Anne De Silva. "Lifetime quality of life and cost consequences of delays in endovascular treatment for acute ischaemic stroke: a cost-effectiveness analysis from a Singapore healthcare perspective." BMJ Open 10, no. 9 (September 2020): e036517. http://dx.doi.org/10.1136/bmjopen-2019-036517.
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ObjectivesEndovascular therapy (EVT) significantly improves clinical outcomes in patients with acute ischaemic stroke (AIS), while the time of EVT initiation after stroke onset influences both patient clinical outcomes and healthcare costs. This study determined the impact of EVT treatment delay on cost effectiveness of EVT in the Singapore healthcare setting.DesignA short-term decision tree and long-term Markov health state transition model was constructed. For each time window of symptom onset to EVT, the probability of receiving EVT or non-EVT treatment was varied, thereby varying clinical outcomes (modified Rankin Scale scores), short-term costs and long-term modelled (lifetime) costs; all of which were used in calculating an incremental cost-effectiveness ratio of EVT vs non-EVT treatment. Clinical outcomes and cost data were derived from clinical trials, literature, expert opinion, electronic medical records and community-based surveys from Singapore. Deterministic one-way and probabilistic sensitivity analyses were performed to assess the uncertainty of the model. The willingness to pay for per quality-adjusted life-year (QALY) was set to Singapore $50 000 (US$36 500).SettingSingapore healthcare perspective.ParticipantsThe model included patients with AIS in Singapore.InterventionsEVT performed within 6 hours of stroke onset.Outcome measuresThe model estimated incremental cost-effectiveness ratios (ICERs) and net monetary benefits (NMB) for EVT versus non-EVT treatment, varied by time from symptom onset to time of treatment.ResultsEVT performed between 61 min and 120 min after the stroke onset was most cost-effective time window to perform EVT in the Singapore population, with an ICER of Singapore $7197 per QALY (US$5254) for performing EVT at 61–120 min versus 121–180 min. The resulting incremental NMB associated with receipt of EVT at the earlier time point is Singapore $39 827 (US$29 074) per patient at the willingness-to-pay threshold of Singapore $50 000. Each hour delay in EVT resulted in an average loss of 0.54 QALYs and 195.35 healthy days, with an average net monetary loss of Singapore $26 255 (US$19 166).ConclusionsFrom the Singapore healthcare perspective, although EVT is more expensive than alternative treatments in the short term, the lifetime ICER is below the willingness-to-pay threshold. Thus, healthcare policies and procedures should aim to improve efficiency of pre-hospital and in-hospital workflow processes to reduce the onset-to-puncture duration.
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Ogoyama, Manabu, Akihide Ohkuchi, Hironori Takahashi, Dongwei Zhao, Shigeki Matsubara, and Toshihiro Takizawa. "LncRNA H19-Derived miR-675-5p Accelerates the Invasion of Extravillous Trophoblast Cells by Inhibiting GATA2 and Subsequently Activating Matrix Metalloproteinases." International Journal of Molecular Sciences 22, no. 3 (January 27, 2021): 1237. http://dx.doi.org/10.3390/ijms22031237.
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The invasion of extravillous trophoblast (EVT) cells into the maternal decidua, which plays a crucial role in the establishment of a successful pregnancy, is highly orchestrated by a complex array of regulatory mechanisms. Non-coding RNAs (ncRNAs) that fine-tune gene expression at epigenetic, transcriptional, and post-transcriptional levels are involved in the regulatory mechanisms of EVT cell invasion. However, little is known about the characteristic features of EVT-associated ncRNAs. To elucidate the gene expression profiles of both coding and non-coding transcripts (i.e., mRNAs, long non-coding RNAs (lncRNAs), and microRNAs (miRNAs)) expressed in EVT cells, we performed RNA sequencing analysis of EVT cells isolated from first-trimester placentae. RNA sequencing analysis demonstrated that the lncRNA H19 and its derived miRNA miR-675-5p were enriched in EVT cells. Although miR-675-5p acts as a placental/trophoblast growth suppressor, there is little information on the involvement of miR-675-5p in trophoblast cell invasion. Next, we evaluated a possible role of miR-675-5p in EVT cell invasion using the EVT cell lines HTR-8/SVneo and HChEpC1b; overexpression of miR-675-5p significantly promoted the invasion of both EVT cell lines. The transcription factor gene GATA2 was shown to be a target of miR-675-5p; moreover, small interfering RNA-mediated GATA2 knockdown significantly promoted cell invasion. Furthermore, we identified MMP13 and MMP14 as downstream effectors of miR-675-5p/GATA2-dependent EVT cell invasion. These findings suggest that miR-675-5p-mediated GATA2 inhibition accelerates EVT cell invasion by upregulating matrix metalloproteinases.
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Balodis, Arturs, Maija Radzina, Evija Miglane, Anthony Rudd, Andrejs Millers, Janis Savlovskis, and Karlis Kupcs. "Endovascular thrombectomy in anterior circulation stroke and clinical value of bridging with intravenous thrombolysis." Acta Radiologica 60, no. 3 (June 6, 2018): 308–14. http://dx.doi.org/10.1177/0284185118780897.
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Background Bridging treatment with intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) in acute ischemic stroke is applied under the assumption of benefits for patients with large vessel occlusion (LVO). However, the benefit of this additional step has not yet been proven. Purpose To compare procedural parameters (procedural time, number of attempts), complications, and clinical outcome in patients receiving EVT vs. patients with bridging treatment. Material and Methods In this prospective study all patients had acute anterior cerebral circulation occlusion and were treated with EVT. All patients were selected for treatment based on clinical criteria, multimodal computed tomography (CT) imaging. Eighty-four patients were treated with bridging IVT followed by EVT; 62 patients were treated with EVT only. Results Bridging therapy did not influence endovascular procedure time ( P = 0.71) or number of attempts needed ( P = 0.63). Bleeding from any site was more common in the bridging group (27, 32%) vs. the EVT group (12, 19%) ( P = 0.09). Functional independence modified Rankin Scale after 90 days was slightly higher in the bridging group (44%) vs. the EVT group (42%) ( P = 0.14). Mortality did not differ significantly at 90 days: 17% in the bridging group vs. 21% in EVT alone ( P = 0.57). Both treatment methods showed high recanalization rates: 94% in the bridging group and 89% for EVT alone. Conclusion Bridging treatment in LVO did not show benefits or elevated risks of complications in comparison to EVT only. The bridging group did not show significantly better neurological outcome or significant impact on procedural parameters vs. EVT alone.
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Zhou, Minerva H., and Akash P. Kansagra. "Changes in Patient Volumes and Outcomes After Adding Thrombectomy Capability." Stroke 52, no. 6 (June 2021): 2143–49. http://dx.doi.org/10.1161/strokeaha.120.032389.
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Background and Purpose: With the rising demand for endovascular thrombectomy (EVT) and introduction of thrombectomy-capable stroke centers (TSC), there is interest among existing stroke hospitals to add EVT capability to attract and retain stroke patient referrals. In this work, we quantify changes in patient volumes and outcomes when adding EVT capability to an existing stroke center. Methods: In MATLAB 2017a Simulink, we simulate a 3-center system comprising an EVT-capable comprehensive stroke center, an EVT-incapable primary stroke center, and an EVT-incapable primary stroke center that gains EVT capability (TSC). We model these changes in 2 geographic settings (urban and rural) using 2 routing paradigms (Nearest Center and Bypass). In Nearest Center, patients are sent to the nearest center regardless of EVT capability. In Bypass, patients with severe strokes are sent to the nearest EVT-capable center, and all others are sent to the nearest center. Probability of good clinical outcome is determined by type and timing of treatment using outcomes reported in clinical trials. Results: Adding EVT capability in the Bypass model produced an absolute increase of 40.1% in total volume of patients with stroke and 31.2% to 31.9% in total volume of acute stroke treatments at the TSC. In the Nearest Center model, the total volume of patients with stroke did not change, but total volume of acute stroke treatment at the TSC had an absolute increase of 9.3% to 9.5%. Good clinical outcomes saw an absolute increase of 0.2% to 0.6% in the whole population and 0.3% to 1.8% in the TSC population. Conclusions: Adding EVT capability shifts patient and treatment volume to the TSC. However, these changes produce modest improvement in overall population health. Health systems should weigh relative hospital and patient benefits when considering adding EVT capability.
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Teryaev, Vladimir E., Sergey Yu Kazakov, and Jay L. Hirshfield. "Multi-beam linear accelerator EVT." Nuclear Instruments and Methods in Physics Research Section A: Accelerators, Spectrometers, Detectors and Associated Equipment 829 (September 2016): 221–23. http://dx.doi.org/10.1016/j.nima.2016.03.066.
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Katzen, Barry T. "The Guidant/EVT Ancure Device." Journal of Vascular and Interventional Radiology 11, no. 2 (February 2000): 62–66. http://dx.doi.org/10.1016/s1051-0443(00)70043-1.
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Paul, Samit, and Prateek Sharma. "Improved VaR forecasts using extreme value theory with the Realized GARCH model." Studies in Economics and Finance 34, no. 2 (June 5, 2017): 238–59. http://dx.doi.org/10.1108/sef-05-2015-0139.
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Purpose This study aims to forecast daily value-at-risk (VaR) for international stock indices by using the conditional extreme value theory (EVT) with the Realized GARCH (RGARCH) model. The predictive ability of this Realized GARCH-EVT (RG-EVT) model is compared with those of the standalone GARCH models and the conditional EVT specifications with standard GARCH models. Design/methodology/approach The authors use daily data on returns and realized volatilities for 13 international stock indices for the period from 1 January 2003 to 8 October 2014. One-step-ahead VaR forecasts are generated using six forecasting models: GARCH, EGARCH, RGARCH, GARCH-EVT, EGARCH-EVT and RG-EVT. The EVT models are implemented using the two-stage conditional EVT framework of McNeil and Frey (2000). The forecasting performance is evaluated using multiple statistical tests to ensure the robustness of the results. Findings The authors find that regardless of the choice of the GARCH model, the two-stage conditional EVT approach provides significantly better out-of-sample performance than the standalone GARCH model. The standalone RGARCH model does not perform better than the GARCH and EGARCH models. However, using the RGARCH model in the first stage of the conditional EVT approach leads to a significant improvement in the VaR forecasting performance. Overall, among the six forecasting models, the RG-EVT model provides the best forecasts of daily VaR. Originality/value To the best of the authors’ knowledge, this is the earliest implementation of the RGARCH model within the conditional EVT framework. Additionally, the authors use a data set with a reasonably long sample period (around 11 years) in the context of high-frequency data-based forecasting studies. More significantly, the data set has a cross-sectional dimension that is rarely considered in the existing VaR forecasting literature. Therefore, the findings are likely to be widely applicable and are robust to the data snooping bias.
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Kakita, Hiroto, Shinichi Yoshimura, Kazutaka Uchida, Nobuyuki Sakai, Hiroshi Yamagami, Takeshi Morimoto, Ryosuke Doijiri, et al. "Impact of Endovascular Therapy in Patients With Large Ischemic Core." Stroke 50, no. 4 (April 2019): 901–8. http://dx.doi.org/10.1161/strokeaha.118.024646.
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Background and Purpose— Endovascular therapy (EVT) is strongly recommended for acute cerebral large vessel occlusion with the Alberta Stroke Program Early CT Score (ASPECTS) ≥6 due to occlusion of the internal carotid artery or M1 segment of the middle cerebral artery. However, the effect of EVT for patients who have ischemic core with ASPECTS ≤5 (0–5) was not established. The purpose of this study was to elucidate the outcomes of EVT for patients with large ischemic core. Methods— Based on the data of The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2, patients with internal carotid artery or M1 segment of the middle cerebral artery occlusion and pretreatment ASPECTS 0 to 5 on noncontrast CT or diffusion-weighted image were extracted, and the outcomes by EVT were analyzed. Primary end point was defined as a good functional outcome (modified Rankin Scale score of ≤2) after 90 days. Result— Among 2420 registered patients, 504 patients were with internal carotid artery or M1 segment of the middle cerebral artery occlusion and ASPECTS 0 to 5. Among these 504 patients, 172 (34.1 %) were treated with EVT (EVT group) and 332 (65.9 %) without (no-EVT group). In the no-EVT group, elderly patients, females, poor prestroke modified Rankin Scale, high National Institutes of Health Stroke Scale, low ASPECTS, and late admission were significantly more observed. Good functional outcomes were significantly more observed in the EVT group than in the no-EVT group (19.8 % versus 4.2 %; P <0.0001; adjusted odds ratio, 2.33; 95% CI, 1.10–4.94). The incidences of symptomatic intracranial hemorrhage within 72 hours did not significantly different between the EVT group and the no-EVT group (3.7 % versus 4.9%; P =0.55; adjusted odds ratio, 0.50; 95% CI, 0.14–1.73). Conclusions— Although outcomes in this group of patients were usually poor, the data suggested EVT may increase the likelihood of a good functional outcome.
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SUDINA, NI WAYAN UCHI YUSHI ARI, KOMANG DHARMAWAN, and I. WAYAN SUMARJAYA. "ESTIMASI NILAI CONDITIONAL VALUE AT RISK (CVaR) PORTOFOLIO MENGGUNAKAN METODE EVT-GJR-VINE COPULA." E-Jurnal Matematika 8, no. 1 (February 2, 2019): 15. http://dx.doi.org/10.24843/mtk.2019.v08.i01.p230.
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Conditional value at risk (CVaR) is widely used in risk measure that takes into account losses exceeding the value at risk level. The aim of this research is to compare the performance of the EVT-GJR-vine copula method and EVT-GARCH-vine copula method in estimating CVaR of the portfolio using backtesting. Based on the backtesting results, it was found that the EVT-GJR-vine copula method have better performance when compared to the EVT-GARCH-vine copula method in estimating the CVaR value of the portfolio. This can be seen from the statistical values ??, and of EVT-GJR-vine copula method which is generally smaller than the statistical values , and of the EVT-GARCH-vine copula method.
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Maslias, Errikos, Stefania Nannoni, Federico Ricciardi, Bruno Bartolini, Davide Strambo, Francesco Puccinelli, Steven David Hajdu, Ashraf Eskandari, Guillaume Saliou, and Patrik Michel. "Procedural Complications During Early Versus Late Endovascular Treatment in Acute Stroke." Stroke 52, no. 3 (March 2021): 1079–82. http://dx.doi.org/10.1161/strokeaha.120.031349.
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Background and Purpose: Endovascular treatment (EVT) in acute ischemic stroke is effective in the late time window in selected patients. However, the frequency and clinical impact of procedural complications in the early versus late time window has received little attention. Methods: We retrospectively studied all acute ischemic strokes from 2015 to 2019 receiving EVT in the Acute Stroke Registry and Analysis of Lausanne. We compared the procedural EVT complications in the early (<6 hours) versus late (6–24 hours) window and correlated them with short-term clinical outcome. Results: Among 695 acute ischemic strokes receiving EVT (of which 202 were in the late window), 113 (16.3%) had at least one procedural complication. The frequency of each single, and for overall procedural complications was similar for early versus late EVT (16.2% versus 16.3%, P adj =0.90). Procedural complications lead to a significantly less favorable short-term outcome, reflected by the absence of National Institutes of Health Stroke Scale improvement in late EVT (delta-National Institutes of Health Stroke Scale-24 hours, −2.5 versus 2, P adj =0.01). Conclusions: In this retrospective analysis of consecutive EVT, the frequency of procedural complications was similar for early and late EVT patients but very short-term outcome seemed less favorable in late EVT patients with complications.
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Tilburgs, Tamara, Ângela C. Crespo, Anita van der Zwan, Basya Rybalov, Towfique Raj, Barbara Stranger, Lucy Gardner, Ashley Moffett, and Jack L. Strominger. "Human HLA-G+ extravillous trophoblasts: Immune-activating cells that interact with decidual leukocytes." Proceedings of the National Academy of Sciences 112, no. 23 (May 26, 2015): 7219–24. http://dx.doi.org/10.1073/pnas.1507977112.
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Invading human leukocyte antigen-G+ (HLA‐G+) extravillous trophoblasts (EVT) are rare cells that are believed to play a key role in the prevention of a maternal immune attack on foreign fetal tissues. Here highly purified HLA‐G+ EVT and HLA‐G− villous trophoblasts (VT) were isolated. Culture on fibronectin that EVT encounter on invading the uterus increased HLA‐G, EGF-Receptor-2, and LIF-Receptor expression on EVT, presumably representing a further differentiation state. Microarray and functional gene set enrichment analysis revealed a striking immune-activating potential for EVT that was absent in VT. Cocultures of HLA‐G+ EVT with sample matched decidual natural killer cells (dNK), macrophages, and CD4+ and CD8+ T cells were established. Interaction of EVT with CD4+ T cells resulted in increased numbers of CD4+CD25HIFOXP3+CD45RA+ resting regulatory T cells (Treg) and increased the expression level of the Treg-specific transcription factor FOXP3 in these cells. However, EVT did not enhance cytokine secretion in dNK, whereas stimulation of dNK with mitogens or classical natural killer targets confirmed the distinct cytokine secretion profiles of dNK and peripheral blood NK cells (pNK). EVT are specialized cells involved in maternal–fetal tolerance, the properties of which are not imitated by HLA‐G–expressing surrogate cell lines.
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Paiva, Premila, Lois A. Salamonsen, Ursula Manuelpillai, Claire Walker, Alejandro Tapia, Euan M. Wallace, and Evdokia Dimitriadis. "Interleukin-11 Promotes Migration, But Not Proliferation, of Human Trophoblast Cells, Implying a Role in Placentation." Endocrinology 148, no. 11 (November 1, 2007): 5566–72. http://dx.doi.org/10.1210/en.2007-0517.
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Trophoblast growth and invasion of the uterine endometrium are critical events during placentation and are tightly regulated by factors produced within the trophoblast-endometrial microenvironment. Deficiencies in placentation can result in early miscarriage or preeclampsia and intrauterine growth restriction, leading to impaired fetal health. The latter has been linked to major adult health disorders. IL-11 is essential for blastocyst implantation in mice. In humans, IL-11 and its receptor IL-11 receptor α (IL-11Rα) are maximally expressed in the decidua and chorionic villi during early pregnancy; however, the role of IL-11 in trophoblast function is unknown. Therefore, we examined whether IL-11Rα is expressed in human first trimester implantation sites, and whether IL-11 influences proliferation and migration of a human extravillous trophoblast (EVT)-hybridoma cell line and primary EVT cells, used as models for EVT. Immunoreactive IL-11Rα localized to subpopulations of interstitial and endovascular EVT cells in vivo. In EVT cells in vitro, IL-11: 1) stimulated phosphorylation of signal transducer and activator of transcription-3; 2) was without effect on EVT cell proliferation; and 3) stimulated significant migration of EVT-hybridoma cells (no endogenous IL-11), whereas in primary EVT, blocking endogenous IL-11 inhibited EVT migration by 30–40%. These data demonstrate that IL-11 stimulates human EVT migration, but not proliferation, likely via signal transducer and activator of transcription-3, indicating an important role for IL-11 in placentation.
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Hinsenveld, Wouter H., Inger R. de Ridder, Robert J. van Oostenbrugge, Wim H. van Zwam, Jan Albert Vos, Jonathan M. Coutinho, Geert J. Lycklama à Nijeholt, Jelis Boiten, and Wouter J. Schonewille. "Intravenous Thrombolysis Is Not Associated with Increased Time to Endovascular Treatment." Cerebrovascular Diseases 49, no. 3 (2020): 321–27. http://dx.doi.org/10.1159/000508898.
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Background: Endovascular treatment (EVT) with or without intravenous thrombolysis (IVT) is effective and safe in ischemic stroke caused by large vessel occlusion, but IVT might delay time to EVT or increase risk of intracranial hemorrhage (ICH). We assessed the influence of prior IVT on time to treatment and risk of ICH in patients treated with EVT. Methods: We analyzed data from the MR CLEAN Registry and included patients with an anterior circulation occlusion treated with EVT who presented directly to an intervention center, between 2014 and 2017. Primary endpoint was the door to groin time. Secondary outcomes were workflow time intervals and safety outcomes. We compared patients who received EVT only with patients who received IVT prior to EVT. Results: We included 1,427 patients directly referred to an intervention center of whom 1,023 (72%) received IVT + EVT. Adjusted door to CT imaging and door to groin time were shorter in IVT + EVT patients (difference 5.7 min [95% CI: 4.6–6.8] and 7.0 min [95% CI: 2.4–12], respectively) while CT imaging to groin time was similar between the groups. Early recanalization on digital subtraction angiography before EVT was seen more often after prior IVT (11 vs. 5.2%, aOR 2.4 [95% CI: 1.4–4.2]). Rates of symptomatic ICH were similar. Conclusion: Prior IVT did not delay door to groin times and was associated with higher rates of early recanalization, without increasing the risk of ICH. Our results do not warrant withholding IVT prior to EVT.
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Wang, Alice S., Jessica K. Campos, Geoffrey P. Colby, Alexander L. Coon, and Li-Mei Lin. "Cerebral aneurysm treatment trends in National Inpatient Sample 2007–2016: endovascular therapies favored over surgery." Journal of NeuroInterventional Surgery 12, no. 10 (March 18, 2020): 957–63. http://dx.doi.org/10.1136/neurintsurg-2019-015702.
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BackgroundFlow modulation is the newest endovascular technique for treatment of cerebral aneurysms.ObjectiveTo investigate changes in aneurysm treatment practice patterns in the USA.MethodsFrom the 2007 to 2016, the National Inpatient Sample databases, hospital discharges associated with unruptured aneurysms (UA), and/or ruptured aneurysms (RA) having undergone surgical clipping (SC) and/or endovascular treatments (EVT) were identified using the International Classification of Diseases codes. Patient demographics, hospital characteristics, and clinical outcomes were reviewed. Five year subgroup analyses were performed for treatment differences.ResultsA total of 39 282 hospital discharges were identified with a significant increase in EVT (UA: SC n=7847 vs EVT n=12 797, p<0.001; RA: SC n=8108 vs EVT n=10 530, p<0.001). Hospitals in the South demonstrated the most significant EVT use regardless of aneurysm status (UA: SC n=258.5±53.6 vs EVT n=480.7±155.8, p<0.001; RA: SC n=285.6±54.3 vs EVT n=393.3±102.9, p=0.003). From 2007 to 2011, there was no significant difference in the mean number of cases for the treatment modalities (UA: SC n=847.4±107.7 vs EVT n=1120.4±254.1, p=0.21; RA: SC n=949.4±52.8 vs EVT n=1054.4±219.6, p=0.85). Comparatively, from 2012 to 2016, significantly more UA and RA were treated endovascularly (UA: SC n=722.0±43.4 vs EVT n=1439.0±419.2, p<0.001; RA: SC n=672.2±61.4 vs EVT n=1051.6±330.2, p=0.02).ConclusionsAs technological innovations continue to advance the neuroendovascular space, the standard of care for treatment of cerebral aneurysms is shifting further towards endovascular therapies over open surgical approaches in the USA.
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Jung, Da Hyun, Hae-Ryong Yun, Se Joon Lee, Na Won Kim, and Cheal Wung Huh. "Endoscopic Vacuum Therapy in Patients with Transmural Defects of the Upper Gastrointestinal Tract: A Systematic Review with Meta-Analysis." Journal of Clinical Medicine 10, no. 11 (May 27, 2021): 2346. http://dx.doi.org/10.3390/jcm10112346.
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A transmural defect of the upper gastrointestinal (UGI) tract is a life-threatening condition associated with high morbidity and mortality. Recently, endoscopic vacuum therapy (EVT) was used for managing UGI defects and showed promising results. We conducted a systematic review and meta-analysis to synthesize evidence on the efficacy of EVT in patients with transmural defects of the UGI tract. We searched the PubMed, Cochrane Library, and Embase databases for publications on the effect of EVT on successful closure, mortality, complications, and post-EVT strictures. Methodological quality was assessed using the Newcastle–Ottawa quality assessment scale. This meta-analysis included 29 studies involving 498 participants. The pooled estimate rate of successful closure with EVT was 0.85 (95% confidence interval [CI]: 0.81–0.88). The pooled estimate rates for mortality, complications, and post-EVT strictures were 0.11, 0.10, and 0.14, respectively. According to the etiology of the transmural defect (perforation vs. leak and fistula), no significant difference was observed in successful closure (odds ratio [OR]: 1.45, 95% CI: 0.45–4.67, p = 0.53), mortality (OR: 0.77, 95% CI: 0.24–2.46, p = 0.66), complications (OR: 0.94, 95% CI: 0.17–5.15, p = 0.94), or post-EVT stricture rates (OR: 0.70, 95% CI: 0.12–4.24, p = 0.70). The successful closure rate was significantly higher with EVT than with self-expanding metal stent (SEMS) placement (OR: 3.14, 95% CI: 1.23–7.98, p = 0.02). EVT is an effective and safe treatment for leaks and fistulae, as well as for perforations in the UGI. Moreover, EVT seems to be a better treatment option than SEMS placement for UGI defects.
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Ganesh, A., N. Kashani, JM Ospel, AT Wilson, MM Foss, G. Saposnik, MA Al-Mekhlafi, M. Goyal, BK Menon, and MD Hill. "P.190 Choosing Endovascular Treatment or Thrombolysis in Patients with Pre-stroke Comorbidities: UNMASK EVT, a Worldwide Survey." Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques 48, s3 (November 2021): S75. http://dx.doi.org/10.1017/cjn.2021.466.
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Background: Decisions to treat large-vessel occlusion with endovascular therapy(EVT) or intravenous alteplase depend on how physicians weigh benefits against risks when considering patients’ pre-stroke comorbidities. Methods: In an international survey, experts chose treatment approaches under current resources and under assumed ideal conditions for 10 of 22 randomly assigned case-scenarios. Five included comorbidities(metastatic/non-metastatic cancer, cardiac/respiratory/renal disease, non-disabling/mild cognitive impairment[MCI], physical dependence). We examined scenario/respondent characteristics associated with EVT/alteplase decisions using multivariable logistic regressions. Results: Among 607 physicians(38 countries), EVT was favoured in 1,097/1,379(79.6%) responses for comorbidity-related scenarios under current resources versus 1,510/1,657(91.1%,OR:0.38, 95%CI.0.31-0.47) for six “level-1A” scenarios (assuming ideal conditions:82.7% vs 95.1%,OR:0.25,0.19-0.33). However, this was reversed on including all other scenarios(e.g. under current resources:3,489/4,691[74.4%], OR:1.34,1.17-1.54). Responses favouring alteplase for comorbidity-related(e.g.75.0% under current resources) scenarios were comparable to level-1A scenarios(72.2%) and higher than all others(60.4%). No comorbidity-related factor independently diminished EVT-odds. MCI and dependence carried higher alteplase-odds; cancer and cardiac/respiratory/renal disease had lower odds. Relevant respondent characteristics included performing more EVT cases/year (higher EVT, lower alteplase-odds), practicing in East-Asia (higher EVT-odds), and in interventional neuroradiology(lower alteplase-odds vs neurology). Conclusions: Moderate-to-severe comorbidities did not consistently deter experts from EVT, suggesting equipoise about withholding EVT based on comorbidities. However, alteplase was often foregone when respondents chose EVT.
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Erickson-DiRenzo, Elizabeth, C. Kwang Sung, Allen L. Ho, and Casey H. Halpern. "Intraoperative Evaluation of Essential Vocal Tremor in Deep Brain Stimulation Surgery." American Journal of Speech-Language Pathology 29, no. 2 (May 8, 2020): 851–63. http://dx.doi.org/10.1044/2019_ajslp-19-00079.
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Purpose Essential vocal tremor (EVT) is a prevalent and difficult-to-manage voice disorder. There is evidence that deep brain stimulation (DBS) of the ventral intermediate nucleus (Vim) of the thalamus may be beneficial for treating EVT. The objective of this preliminary investigation was to conduct intraoperative voice assessments during Vim-DBS implantation in order to evaluate immediate voice outcomes in medication-refractory essential tremor patients with co-occurring EVT. Method Seven adult subjects diagnosed with EVT undergoing Vim-DBS surgery participated in this investigation. Voice samples of sustained vowels were collected by a speech-language pathologist preoperatively and intraoperatively, immediately following Vim-DBS electrode placement. Voice evaluation included objective acoustic assessment of the rate and extent of EVT fundamental frequency and intensity modulation and subjective perceptual ratings of EVT severity. Results The rate of intensity modulation, extent of fundamental frequency modulation, and perceptual rating of EVT severity were significantly reduced intraoperatively as compared to preoperatively. Moderate, positive correlations were appreciated between a subset of acoustic measures and perceptual severity ratings. Conclusions The results of this study demonstrate a speech-language pathologist can conduct intra-operative evaluation of EVT during DBS surgery. Using a noninvasive, simple acoustic recording method, we were able to supplement perceptual subjective observation with objective assessment and demonstrate immediate, intraoperative improvements in EVT. The findings of this analysis inform the added value of intraoperative voice evaluation in Vim-DBS patients and contribute to the growing body of literature seeking to evaluate the efficacy of DBS as a treatment for EVT.
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Morey, Jacob R., Neha S. Dangayach, Hazem Shoirah, Jacopo Scaggiante, J. Mocco, Stanley Tuhrim, Johanna T. Fifi, and for the Mount Sinai Stroke Investigators. "Major Causes for Not Performing Endovascular Therapy Following Inter-Hospital Transfer in a Complex Urban Setting." Cerebrovascular Diseases 48, no. 3-6 (2019): 109–14. http://dx.doi.org/10.1159/000503716.
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Introduction: Endovascular therapy (EVT) has emerged as the standard of care for emergent large vessel occlusion (ELVO) acute ischemic stroke. An increasing number of patients with suspected ELVO are being transferred to stroke centers with interventional capacity. Not all such inter-hospital transfers result in EVT. Aim: To identify the major causes for not performing EVT following transfer. Methods: An analysis of 222 consecutive patients with suspected ELVO transferred for potential EVT between January 2015 and December 2017 within a New York City health system was performed. About 36% (80/222) were deemed EVT ineligible and compared to an EVT cohort. Results: Major causes for not performing EVT were established infarct (34%), no or recanalized ELVO (31%), and mild or clinically improved symptoms (21%). In the established infarct subgroup, 28% (7/27) arrived at a stroke center with interventional capacity within 5 h of last known well, compared to 61% (83/142) in the EVT cohort (p = 0.003). In the no or recanalized ELVO subgroup, 40% (10/25) received computed tomographic angiography at the primary stroke center (PSC), compared to 73% (104/142) in the EVT cohort (p = 0.001). Among patients treated with intravenous thrombolysis, 6% (6/104) improved from a NIHSS of ≥6 to <6 following transfer. Conclusions: Established infarct, no or recanalized ELVO, and mild or clinically improved symptoms were the major causes for not performing EVT for patients transferred for ELVO management. These may be addressed by decreasing stroke onset to treatment times and timely ELVO detection at the PSC and/or pre-hospital triage.
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Sang, Hongfei, Fengli Li, Junjie Yuan, Shuai Liu, Weidong Luo, Changming Wen, Qiyi Zhu, et al. "Values of Baseline Posterior Circulation Acute Stroke Prognosis Early Computed Tomography Score for Treatment Decision of Acute Basilar Artery Occlusion." Stroke 52, no. 3 (March 2021): 811–20. http://dx.doi.org/10.1161/strokeaha.120.031371.
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Background and Purpose: This study aimed to analyze the impact of baseline posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) on the efficacy and safety of endovascular therapy (EVT) for patients with acute basilar artery occlusion. Methods: The BASILAR was a nationwide prospective registry of consecutive patients with a symptomatic and radiologically confirmed acute basilar artery occlusion within 24 hours of symptom onset. We estimated the effect of standard medical therapy alone (SMT group) versus SMT plus EVT (EVT group) for patients with documented pc-ASPECTS on noncontrast CT, both as a categorical (0–4 versus 5–7 versus 8–10) and as a continuous variable. The primary outcomes included favorable functional outcomes (modified Rankin Scale ≤3) at 90 days and mortality within 90 days. Results: In total, 823 cases were included: 468 with pc-ASPECTS 8 to 10 (SMT: 71; EVT: 397), 317 with pc-ASPECTS 5 to 7 (SMT: 85; EVT: 232), and 38 with pc-ASPECTS 0 to 4 (SMT: 13; EVT: 25). EVT was associated with higher rate of favorable outcomes (adjusted relative risk with 95% CI, 4.35 [1.30–14.48] and 3.20 [1.68–6.09]; respectively) and lower mortality (60.8% versus 77.6%, P =0.005 and 35.0% versus 66.2%, P< 0.001; respectively) than SMT in the pc-ASPECTS 5 to 7 and 8 to 10 subgroups. Continuous benefit curves also showed the superior efficacy and safety of EVT over SMT in patients with pc-ASPECTS ≥5. Furthermore, the prognostic effect of onset to puncture time on favorable outcome with EVT was not significant after adjustment for pc-ASPECTS (adjusted odds ratio, 0.98 [95% CI, 0.94–1.02]). Conclusions: Patients of basilar artery occlusion with pc-ASPECTS ≥5 could benefit from EVT. The baseline pc-ASPECTS appears more important for decision making and predicting prognosis than time to EVT. Registration: URL: http://www.chictr.org.cn . Unique identifier: ChiCTR1800014759.
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Sarraj, Amrou, James C. Grotta, Sheryl Martin-Schild, Haris Kamal, Anjail Z. Sharrief, Kirsten Carroll, Faris Shaker, Deep K. Pujara, Louise D. McCullough, and Sean I. Savitz. "Abstract 29: Optimization Methodologies to Enhance Endovascular Thrombectomy Access in the United States." Stroke 51, Suppl_1 (February 2020). http://dx.doi.org/10.1161/str.51.suppl_1.29.
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Background: Timely access to endovascular thrombectomy (EVT) centers is vital for best stroke outcome. We map current EVT access in the US then utilize modeling to optimize it. Methods: US designated stroke centers were mapped utilizing geo-mapping and stratified into EVT or non-EVT if they reported ≥1 thrombectomy code for acute ischemic stroke in 2017 to CMS. Direct EVT access, defined as the population with the closest facility to EVT centers, was calculated from validated trauma models adapted for stroke. Current 15 and 30 min access were described nationwide and in 4 states (TX, NY, CA, IL). Two optimization models were utilized. Model A used a greedy algorithm to capture the largest population with direct access when flipping 10 non-EVT to EVT centers to maximize access. Model B used bypassing methodology to directly transport patients to EVT centers within 15 min from the closest non-EVT center. Results: Of 1941 stroke centers, 714 were EVT. Approximately 99 million/32% Americans have direct EVT access within 15 min while 111 million (36.0%) within 30 minutes (Fig 1). There were 65 (43%) EVT centers in TX with 22% current 15 min access. Flipping the top 10 population density hospitals improved access to 32%, while bypassing resulted in 46% having direct access to EVT centers (fig 2 A-B). Direct access in CA was 26% which improved to 35% with flipping and 54% by 15 min bypassing from the closest non-EVT to EVT centers. Similar results were found in NY (current 21%, flipping 39%, bypassing 50%) and IL (15%, 27% and 35%, respectively), Tab 1. Conclusion: EVT access within 15 min is limited to less than 1/3 of the US population. Optimization methodology that increase EVT centers or bypass non-EVT to the closest EVT center both showed enhanced access. Results varied by states based on the population size and density. However, bypass showed more potential for maximizing direct EVT access. National and state efforts should focus on identifying gaps and tailoring solutions to improve EVT access.
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Yun, Jae Ho. "Evt Caviar (Var Forecasts for Korea Treasurybonds Via Evt and Caviar Models)." SSRN Electronic Journal, 2018. http://dx.doi.org/10.2139/ssrn.3204997.
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Kaczmarek, Dominik J., Dominik J. Heling, Maria A. Gonzalez-Carmona, Christian P. Strassburg, Vittorio Branchi, Hanno Matthaei, Jörg Kalff, Steffen Manekeller, Tim R. Glowka, and Tobias J. Weismüller. "Management of post-operative pancreatic fistulas following Longmire–Traverso pylorus-preserving pancreatoduodenectomy by endoscopic vacuum-assisted closure therapy." BMC Gastroenterology 21, no. 1 (November 12, 2021). http://dx.doi.org/10.1186/s12876-021-02000-3.
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Abstract Background Pylorus-preserving pancreatoduodenectomy (PPPD) with pancreatogastrostomy is a standard surgical procedure for pancreatic head tumors, duodenal tumors and distal cholangiocarcinomas. Post-operative pancreatic fistulas (POPF) are a major complication causing relevant morbidity and mortality. Endoscopic vacuum therapy (EVT) has become a widely used method for the treatment of intestinal perforations and leakages. Here we report on a pilot single center series of 8 POPF cases specifically caused by dehiscences of the pancreatogastric anastomosis (PGD), successfully managed by EVT. Methods We included all patients with PGD after PPPD, who were treated with EVT between 07/2017 and 08/2020. For EVT a vacuum drainage film (EVT film) or open-pore polyurethane foam sponge (EVT sponge) was fixed to a 14Fr or 16Fr suction catheter and placed endoscopically within the PGD for intracavitary EVT with continuous suction between − 100 and − 150 mmHg. The EVT film/sponge was exchanged twice per week. EVT was discontinued when the PGD was sufficiently healed. Results PGD closure was achieved in 7 of 8 patients after a mean EVT time of 16 days (range 8–38) and 3 EVT film/sponge exchanges (range 1–9). One patient died on day 18 after PPPD from acute hemorrhagic shock, unlikely related to EVT, before effectiveness of EVT could be fully achieved. There were no adverse events directly attributable to EVT. Conclusions EVT could be an effective and safe addition to our therapeutic armamentarium in the management of POPF with PGD. Unless prospective comparative studies are available, EVT as minimally invasive therapeutic alternative should be considered individually by an interdisciplinary team involving endoscopists, surgeons and radiologists.
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Kenner-brininger, Amelia, Lindsay Olson-Mack, Lorraine Calzone, Kristi L. Koenig, and Thomas M. Hemmen. "Abstract WP37: Endovascular Thrombectomy Practice Pattern Across the Nihss Spectrum." Stroke 51, Suppl_1 (February 2020). http://dx.doi.org/10.1161/str.51.suppl_1.wp37.
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Background: Endovascular thrombectomy (EVT) after Ischemic Stroke (AIS) has shown to improve outcomes in multiple large clinical trials. However, most guidelines recommend EVT for patients with NIHSS greater than 5 and caution EVT in severe stroke. We analyzed data from a stroke registry to learn about ‘real-world’ use of EVT across stroke serverity. Most clinical trials focus on academic medical centers. Our analysis reports on data from all centers within a region. Methods: The San Diego County EMS Stroke Registry represents data from 10 EVT ready centers. We included all AIS cases with NIHSS between 0 and 42 from July 2016 through December 2018. Patients were grouped into three categories: 1) NIHSS 0-5, 2) 6-25, 3) 26-42. We analyzed frequency of EVT use, last known normal (LKN) to skin puncture time, admission NIHSS in EVT cases, and hospital discharge dispositon of EVT cases. Results: Of 7,050 AIS cases, 662 (9.4%) received EVT from July 2016 to December 2018. Group (G) 1: 80 of 4184 cases received EVT (1.9%), G2: 470 of 2502 cases received EVT (18.8%), G3: 112 of 364 cases received EVT (30.8%). Rate of EVT in all AIS and for each NIHSS group did not change (all AIS: p=.24, G1: p=.59, G2: p=.15, G3: p=.57). Mean (±SD) NIHSS among all AIS was 7.4 (±8.5); among EVT cases it was 17.2 (±8.6). Mean (±SD) LKN to skin puncture (hours) was G1: 9.2 (±12.1), G2: 5.8 (±5.8), G3: 5.5 (±5.3) (p=.000001). Mean (±SD) age (years) of EVT cases was G1: 65.5 (±15.4); G2: 71.9 (±15.6); , G3: 77.1 (±14.0) (p=.00001). Discharge to home among EVT cases was Group 1: 50.0%; 2) 26.5%; 3) 9.8%; to a non-acute health care facility: G1) 28.8%, 2) 39.5%, 3) 44.6%); in-hospital death 1) 10.0%, 2) 13.6%, 3) 25.0%. Conclusion: Patients with mild and severe stroke present a significant subpopulation of patients undergoing EVT in this sample. Overall, one in three stroke patients with NIHSS above 25 underwent EVT; less than one in five stroke patients with low NIHSS underwent EVT. Over time there has been no change in the number of patients receiving EVT and no change in EVT use within NIHSS groups. Half of patients with low NIHSS were discharged home; one in four patients with high NIHSS expired in hospital. As hospitals embraced EVT, the use of the procedure among patients with low or high NIHSS has remained consistent.
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Beaman, Charles, Jessalyn K. Holodinsky, Mayank Goyal, Michael D. Hill, Jeffrey L. Saver, and Noreen Kamal. "Abstract TMP32: Modeling Optimal Patient Transport In A Stroke Network Capable Of Telerobotic Endovascular Therapy." Stroke 53, Suppl_1 (February 2022). http://dx.doi.org/10.1161/str.53.suppl_1.tmp32.
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Introduction: Endovascular therapy (EVT) is the standard-of-care for large vessel occlusion stroke; yet, a substantial portion of the population lacks timely access to the treatment. Telerobotics has the potential to expand current stroke networks by offering remote EVT to more rural populations. Methods: We geospatially mapped all existing hospitals in California and then assessed hypothetical scenarios in which primary stroke centers between 50 and 100 miles from an existing EVT center offered remote EVT via robotics. Using an existing conditional probability model, we determined the transport scenarios (drip and ship, direct to robotic EVT center, or direct to conventional EVT center) resulting in best patient outcomes in diverse geographies across the state. Timing and the probability of receiving EVT (used as a surrogate for the probability of receiving successful reperfusion) were varied at robotic centers to assess impact on best predicted transport options. Results: 10 hospitals were converted to robotic EVT centers, resulting in enhanced patient access to timely EVT by routing patients in a rural catchment area of 113,063 km 2 directly to robotic EVT centers (figure). Slowing the door to arterial access time at the robotic centers by 30 minutes had a minor impact on optimized service arrangements (reducing the robotic catchment area to 110,555 km 2 ). However, decreasing the probability of receiving EVT at the robotic centers by 0.10 had a substantial impact, reducing the robotic EVT catchment area to 35,061 km 2 and nearly doubling the drip and ship catchment area. Discussion: Telerobotic EVT has the potential to enhance therapy for stroke patients outside of major urban centers. We found that the reduced probability of receiving EVT had a greater impact on the optimized size of robotic EVT center catchment areas compared to longer door to arterial access times. This modeling analysis can inform system planning for the potential advent of remote robotic EVT care.
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Pallesen, Lars-Peder, Simon Winzer, Christian Hartmann, Matthias Kuhn, Johannes C. Gerber, Hermann Theilen, Kevin Hädrich, et al. "Team Prenotification Reduces Procedure Times for Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion Who Are Transferred for Endovascular Therapy." Frontiers in Neurology 12 (January 3, 2022). http://dx.doi.org/10.3389/fneur.2021.787161.
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Background: The clinical benefit from endovascular therapy (EVT) for patients with acute ischemic stroke is time-dependent. We tested the hypothesis that team prenotification results in faster procedure times prior to initiation of EVT.Methods: We analyzed data from our prospective database (01/2016–02/2018) including all patients with acute ischemic stroke who were evaluated for EVT at our comprehensive stroke center. We established a standardized algorithm (EVT-Call) in 06/2017 to prenotify team members (interventional neuroradiologist, neurologist, anesthesiologist, CT and angiography technicians) about patient transfer from remote hospitals for evaluation of EVT, and team members were present in the emergency department at the expected patient arrival time. We calculated door-to-image, image-to-groin and door-to-groin times for patients who were transferred to our center for evaluation of EVT, and analyzed changes before (–EVT-Call) and after (+EVT-Call) implementation of the EVT-Call.Results: Among 494 patients in our database, 328 patients were transferred from remote hospitals for evaluation of EVT (208 -EVT-Call and 120 +EVT-Call, median [IQR] age 75 years [65–81], NIHSS score 17 [12–22], 49.1% female). Of these, 177 patients (54%) underwent EVT after repeated imaging at our center (111/208 [53%) -EVT-Call, 66/120 [55%] +EVT-Call). Median (IQR) door-to-image time (18 min [14–22] vs. 10 min [7–13]; p < 0.001), image-to-groin time (54 min [43.5–69.25] vs. 47 min [38.3–58.75]; p = 0.042) and door-to-groin time (74 min [58–86.5] vs. 60 min [49.3–71]; p < 0.001) were reduced after implementation of the EVT-Call.Conclusions: Team prenotification results in faster patient assessment and initiation of EVT in patients with acute ischemic stroke. Its impact on functional outcome needs to be determined.
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Agrawal, Kunal, Ilana Spokoyny, Chia-Chun Chiang, Kevin McGehrin, and Brett C. Meyer. "Abstract P284: Coordinating Options for Acute Stroke Therapy (COAST): Demonstrating Patient Autonomy by Examining Preferences for Acute Stroke Treatment From a Stroke Advance Directive." Stroke 52, Suppl_1 (March 2021). http://dx.doi.org/10.1161/str.52.suppl_1.p284.
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Introduction: Respect for patient autonomy is critical, and patients/surrogates may have various preferences about acute stroke treatment that are not fully appreciated during a stroke code. COAST (Coordinating Options for Acute Stroke Therapy) is a stroke advance directive formalizing advanced consent for thrombolysis (tPA) and endovascular therapy (EVT). We examine the distribution of patient preferences to improve understanding and respect for patient autonomy in acute stroke. Methods: In our IRB-approved study, we collected COAST forms at UC San Diego from 12/1/2014-2/29/2020. Patients chose one of five tPA preferences: not under any circumstance (tPA 1); up to 3 hours only, based on FDA approval (tPA 2); up to 4.5 hours only, based on current guidelines (tPA 3); anytime per provider discretion (tPA 4); or other answer (tPA treatment under specific conditions written by the patient/surrogate) (tPA 5). Patients also chose one of five EVT preferences: not under any circumstance (EVT 1); up to 6 hours only (EVT 2); up to 12 hours only (EVT 3); up to 24 hours only (this option replaced "up to 12 hours only" on 3/1/2018 when the 6-24 hour window became standard of care) (EVT 4); anytime at provider discretion (EVT 5); or other answer (EVT treatment under specific conditions written by the patient/surrogate) (EVT 6). Frequency of preferences was calculated for each option. Results: In total, 342 COASTs were completed. Frequency of tPA preferences were: 3.2% for tPA 1 (11/342), 1.5% for tPA 2 (5/342), 25.7% for tPA 3 (88/342), 55.6% for tPA 4 (190/342), 14.0% for tPA 5 (48/342). Frequency of EVT preferences were: 1.8% for EVT 1 (6/342), 9.6% for EVT 2 (33/342), 3.2% for EVT 3 (11/342), 10.8% for EVT 4 (37/342), 62.3% for EVT 5 (213/342), 12.3% for EVT 6 (42/342). When the 6-24 hour window became standard of care, 0% (0/342) chose EVT 2. Total 81.6% (n=279) of COASTs had the same tPA and EVT preferences, and 18.4% (n=63) had tPA preferences that were different from EVT preferences. Conclusion: Preferences vary regarding tPA and EVT treatment. Most patients defer to provider discretion, though some patients have preferences that are different from current provider expectations and/or stroke guidelines. COAST is pivotal to inform respect for patient autonomy for acute stroke codes.
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Lin, Chun-Hsien, Jeffrey L. Saver, Bruce Ovbiagele, Wen-Yi Huang, and Meng Lee. "Endovascular thrombectomy without versus with intravenous thrombolysis in acute ischemic stroke: a non-inferiority meta-analysis of randomized clinical trials." Journal of NeuroInterventional Surgery, July 15, 2021, neurintsurg—2021–017667. http://dx.doi.org/10.1136/neurintsurg-2021-017667.
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ObjectiveTo conduct a meta-analysis of randomized trials to comprehensively compare the effect of endovascular thrombectomy (EVT) versus intravenous thrombolysis (IVT) plus EVT on functional independence (modified Rankin Scale (mRS) 0–2) after acute ischemic stroke due to large vessel occlusions (AIS-LVO).MethodsWe searched Pubmed, EMBASE, CENTRAL, and clinicaltrials.gov from January 2000 to February 2021 and abstracts presented at the International Stroke Conference in March 2021 to identify trials comparing EVT alone versus IVT plus EVT in AIS-LVO. Five non-inferiority margins established in the literature were assessed: −15%, −10%, −6.5%, −5%, and −1.3% for the risk difference for functional independence at 90 days.ResultsFour trials met the selection criteria, enrolling 1633 individuals, with 817 participants randomly assigned to EVT alone and 816 to IVT plus EVT. Crude cumulative rates of 90-day functional independence were 46.0% with EVT alone versus 45.5% with IVT plus EVT. Pooled results showed the risk difference of functional independence was 1% (95% CI −4% to 5%) between EVT alone versus IVT plus EVT. The lower 95% CI bound of −4% fell within the non-inferiority margins of −15%, −10%, −6.5%, and −5%, but not −1.3%. Pooled results also showed the risk difference between EVT alone versus IVT plus EVT was 1% (95% CI −3% to 5%) for mRS 0–1, and 1% (95% CI −1% to 3%) for symptomatic intracranial hemorrhage.ConclusionsThis meta-analysis suggests that EVT alone is non-inferior to IVT plus EVT for several, but not the most stringent, non-inferiority margins.
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Diprose, William K., Michael T. M. Wang, Kaustubha Ghate, Stefan Brew, James R. Caldwell, Ben McGuinness, and P. Alan Barber. "Adjunctive Intraarterial Thrombolysis in Endovascular Thrombectomy: A Systematic Review and Meta-analysis." Neurology, April 30, 2021, 10.1212/WNL.0000000000012112. http://dx.doi.org/10.1212/wnl.0000000000012112.
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ObjectiveTo evaluate the safety and efficacy of intra-arterial thrombolysis (IAT) as an adjunct to endovascular thrombectomy (EVT) in ischemic stroke, we performed a systematic review and meta-analysis of the literature.MethodsSearches were performed using Medline, Embase, and Cochrane databases for studies that compared EVT to EVT with adjunctive IAT (EVT+IAT). Safety outcomes included symptomatic intracerebral hemorrhage (sICH) and mortality at three months. Efficacy outcomes included successful reperfusion (Thrombolysis in Cerebral Infarction score of 2b to 3), and functional independence, defined as a modified Rankin Scale score of 0 to 2 at three months.ResultsFive studies were identified that compared combined EVT+IAT (IA alteplase or urokinase) to EVT-only, and were included in the random effects meta-analysis. There were 1693 EVT patients, including 269 patients treated with combined EVT+IAT and 1424 patients receiving EVT-only. Pooled analysis did not demonstrate any differences between EVT+IAT and EVT-only in rates of sICH (OR: 0.61, 95% CI: 0.20-1.85; P=0.78), mortality (OR: 0.77, 95% CI: 0.54-1.10; P=0.15), or successful reperfusion (OR: 1.05, 95% CI: 0.52-2.15; P=0.89). There was a higher rate of functional independence in patients treated with EVT+IAT, although this was not statistically significant (OR: 1.34, 95% CI: 1.00-1.80; P=0.053).ConclusionsAdjunctive IAT appears to be safe. In specific situations, neurointerventionists may be justified in administering small doses of intraarterial alteplase or urokinase as rescue therapy during EVT.
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Smythe, Ken, and John A. Oostema. "Abstract TP233: Clinical Predictors of Endovascular Stroke Treatment Among Emergency Department Patients Screened With Multimodal Computed Tomography." Stroke 51, Suppl_1 (February 2020). http://dx.doi.org/10.1161/str.51.suppl_1.tp233.
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Background: Endovascular therapy (EVT) offers dramatic benefit to selected patients with large vessel occlusion (LVO) ischemic stroke. However, identification of EVT candidates requires advanced imaging and often interfacility transfer. We sought to quantify the yield of such testing as well as identify clinical predictors of EVT candidacy. Methods: This retrospective cohort study identified consecutive Emergency Department (ED) patients with stroke symptoms who underwent CT angiogram and brain perfusion (CTA/P) imaging to assess for EVT candidacy. Demographics, medical history, clinical characteristics, final diagnosis, and outcomes were abstracted. We compared clinical characteristics among those who did and did not undergo EVT. Multivariable logistic regression was used to identify independent clinical predictors of EVT and derive a clinical prediction rule to quantify the probability of EVT. Results: Over a 12-month period, 835 patients underwent CTA/P imaging in the ED. EVT was undertaken for 116 (13.9%) patients; 321 (38.4%) ultimately received a non-stroke diagnosis. Patients who received EVT were older and had higher stroke scores (Table). Patients with an unknown last known well (LKW) time were less likely to receive EVT, however increasing time form LKW to door did not predict EVT (test for trend p=0.976). Multivariable analysis results are presented in the Table. A clinical decision rule based on the regression coefficients demonstrated moderately high discrimination for predicting EVT with an AUC of 0.79 (0.74 to 0.83). Among 102 patients transferred for CTA/P, 24 (24%) had and a score <1, none of whom received EVT. Conclusions: EVT Candidates are common among ED patients screened with CTA/P. Clinical factors can predict the likelihood of EVT candidacy. If validated in other populations, a simple clinical prediction rule may assist in triaging patients in need of urgent transfer to a thrombectomy-capable facility.
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Kenner-brininger, Amelia, Lindsay Olson-Mack, Lorraine Calzone, Kristi L. Koenig, and Thomas M. Hemmen. "Abstract WP27: Patient Age and Outcomes of Those Receiving Endovascular Thrombectomy Treatment in San Diego County." Stroke 51, Suppl_1 (February 2020). http://dx.doi.org/10.1161/str.51.suppl_1.wp27.
Full textAbstract:
Background: Endovascular thrombectomy (EVT) after Ischemic Stroke (AIS) has shown to improve outcomes in multiple large clinical trials. While most guidelines lifted the age restriction, few patients enrolled in clinical trials were over 79 years of age. We studied EVT over time in San Diego County as it relates to patient age. We sought to understand age distribution of patients receiving EVT, frequency by which patients 79 and older received treatment, and whether that frequency changed over time. Methods: We included AIS patients with a reported age and NIHSS from 10 EVT capable centers from July 2016 through December 2018 from the San Diego County EMS Stroke Registry. We analyzed frequency of EVT by patient age, last known normal (LKN) to groin puncture time, NIHSS and hospital discharge disposition. Results: Between July 2016 and December 2018, of 7,049 AIS patients, 659 (9.3%) received EVT. The mean (±SD) age of EVT patients was 71.9 (±15.6) years, ranging from 24 to 104 years old. Of these patients, 250 (37.9%) were >79 years. On average (±SD), 22.1 (±4.2) patients received EVT per month. Rate of EVT use among all AIS patients did not change over time (p=.24). On average (±SD) 8.4 (±3.3) patients >79 years underwent EVT per month. Rate of EVT among patients >79 years did not change over time (p=.31). EVT rate among patients ≤ 79 years increased over time (p=.02). EVT patients >79 years had a mean (±SD) initial NIHSS of 19.2 (±8.2) compared to EVT patients ≤ 79 years NIHSS 16.0 (±8.6) (p=.000002). Overall mean (±SD) LKN to groin puncture was 6.2 hours (±7.0), >79 years 5.6 (±5.7), ≤ 79 years 6.5 hours (±7.6) (p=.11). EVT patients >79 years were discharged to a Skilled Nursing Facility (SNF) (32.9%), died in-hospital (19.0%), and transferred to acute care (15.9%); patients ≤ 79 years were discharged to home (35.2%), SNF (17.6%), and Inpatient Rehabilitation Facility (15.7%). Conclusion: Endovascular thrombectomy for patients older than 79 years accounts for nearly one in four patients receiving EVT. The frequency of EVT use in the elderly did not change over time while use in patients under age 80 increased slightly. However, overall use of EVT remained consistent. Older patients receiving EVT had a higher NIHSS and were more commonly discharged to a SNF compared to younger patients.
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McDonough, Rosalie, Johanna Ospel, Nima Kashani, Manon Kappelhof, Jianmin Liu, Pengfei Yang, Charles Majoie, Yvo Roos, and Mayank Goyal. "Influence of recent direct-to-EVT trials on practical decision-making for the treatment of acute ischemic stroke patients." Interventional Neuroradiology, November 17, 2021, 159101992110579. http://dx.doi.org/10.1177/15910199211057984.
Full textAbstract:
Background Current guidelines recommend that eligible acute ischemic stroke (AIS) patients receive intravenous alteplase (IVT) prior to endovascular treatment (EVT). Six randomized controlled trials recently sought to determine the risks of administering IVT prior to EVT, five of which have been published/presented. It is unclear whether and how the results of these trials will change guidelines. With the DEBATE survey, we assessed the influence of the recent trials on physicians’ IVT treatment strategies in the setting of EVT for large vessel occlusion (LVO) stroke. Methods Participants were provided with 15 direct-to-mothership case-scenarios of LVO stroke patients and asked whether they would treat with IVT + EVT or EVT alone, a) before publication/presentation of the direct-to-EVT trials, and b) now (knowing the trial results). Logistic regression clustered by respondent was performed to assess factors influencing the decision to adopt an EVT-alone paradigm after publication/presentation of the trial results. Results 289 participants from 37 countries provided 4335 responses, of which 13.5% (584/4335) changed from an IVT + EVT strategy to EVT alone after knowing the trial results. Very few switched from EVT alone to IVT + EVT (8/4335, 0.18%). Scenarios involving a long thrombus (RR 1.88, 95%CI:1.56–2.26), cerebral micro-hemorrhages (RR 1.78, 95%CI:1.43–2.23), and an expected short time to recanalization (RR 1.46 95%CI:1.19–1.78) had the highest chance of participants switching to an EVT-only strategy. Conclusion In light of the recent direct-to-EVT trials, a sizeable proportion of stroke physicians appears to be rethinking IVT treatment strategies of EVT-eligible mothership patients with AIS due to LVO in specific situations.