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Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data

Campbell, Bruce C V; Majoie, Charles B L M; Albers, Gregory W; Menon, Bijoy K; Yassi, Nawaf; Sharma, Gagan; van Zwam, Wim H; van Oostenbrugge, Robert J; Demchuk, Andrew M; Guillemin, Francis; White, Philip; Dávalos, Antoni; van der Lugt, Aad; Butcher, Kenneth S; Cherifi, Aboubaker; Marquering, Henk A; Cloud, Geoffrey; Macho Fernández, Juan M; Madigan, Jeremy; Oppenheim, Catherine; Donnan, Geoffrey A; Roos, Yvo B W E M; Shankar, Jai; Lingsma, Hester; Bonafé, Alain; Raoult, Hélène; Hernández-Pérez, María; Bharatha, Aditya; Jahan, Reza; Jansen, Olav; Richard, Sébastien; Levy, Elad I; Berkhemer, Olvert A; Soudant, Marc; Aja, Lucia; Davis, Stephen M; Krings, Timo; Tisserand, Marie; San Román, Luis; Tomasello, Alejandro; Beumer, Debbie; Brown, Scott; Liebeskind, David S; Bracard, Serge; Muir, Keith W; Dippel, Diederik W J; Goyal, Mayank; Saver, Jeffrey L; Jovin, Tudor G; Hill, Michael D; Mitchell, Peter J; Berkhemer, Olvert A; Fransen, Puck Ss; Beumer, Debbie; van den Berg, Lucie A; Lingsma, Hester F; Yoo, Albert J; Schonewille, Wouter J; Vos, Jan Albert; Nederkoorn, Paul J; Wermer, Marieke Jh; van Walderveen, Marianne Aa; Staals, Julie; Hofmeijer, Jeannette; van Oostayen, Jacques A; Lycklama À Nijeholt, Geert J; Boiten, Jelis; Brouwer, Patrick A; Emmer, Bart J; de Bruijn, Sebastiaan F; van Dijk, Lukas C; Kappelle, Jaap; Lo, Rob H; van Dijk, Ewoud J; de Vries, Joost; de Kort, Paul L M; van Rooij, Willem Jan J; van den Berg, Jan S P; van Hasselt, Boudewijn A A M; Aerden, Leo A M; Dallinga, René J; Visser, Marieke C; Bot, Joseph C J; Vroomen, Patrick C; Eshghi, Omid; Schreuder, Tobien H C M L; Heijboer, Roel J J; Keizer, Koos; Tielbeek, Alexander V; den Hertog, Heleen M; Gerrits, Dick G; van den Berg-Vos, Renske M; Karas, Giorgos B; Steyerberg, Ewout W; Flach, Zwenneke; Marquering, Henk A; Sprengers, Marieke E S; Jenniskens, Sjoerd F M; Beenen, Ludo F M; van den Berg, René; Koudstaal, Peter J; van Zwam, Wim H; Roos, Yvo B W E M; van der Lugt, Aad; van Oostenbrugge, Robert J; Majoie, Charles B L M; Dippel, Diederik W J; Brown, Martin M; Liebig, Thomas; Stijnen, Theo; Andersson, Tommy; Mattle, Heinrich; Wahlgren, Nils; van der Heijden, Esther; Ghannouti, Naziha; Fleitour, Nadine; Hooijenga, Imke; Puppels, Corina; Pellikaan, Wilma; Geerling, Annet; Lindl-Velema, Annemieke; van Vemde, Gina; de Ridder, Ans; Greebe, Paut; de Bont-Stikkelbroeck, José; de Meris, Joke; Janssen, Kirsten; Struijk, Willy; Licher, Silvan; Boodt, Nikki; Ros, Adriaan; Venema, Esmee; Slokkers, Ilse; Ganpat, Raymie-Jayce; Mulder, Maxim; Saiedie, Nawid; Heshmatollah, Alis; Schipperen, Stefanie; Vinken, Stefan; van Boxtel, Tiemen; Koets, Jeroen; Boers, Merel; Santos, Emilie; Borst, Jordi; Jansen, Ivo; Kappelhof, Manon; Lucas, Marit; Geuskens, Ralph; Barros, Renan Sales; Dobbe, Roeland; Csizmadia, Marloes; Hill, M D; Goyal, M; Demchuk, A M; Menon, B K; Eesa, M; Ryckborst, K J; Wright, M R; Kamal, N R; Andersen, L; Randhawa, P A; Stewart, T; Patil, S; Minhas, P; Almekhlafi, M; Mishra, S; Clement, F; Sajobi, T; Shuaib, A; Montanera, W J; Roy, D; Silver, F L; Jovin, T G; Frei, D F; Sapkota, B; Rempel, J L; Thornton, J; Williams, D; Tampieri, D; Poppe, A Y; Dowlatshahi, D; Wong, J H; Mitha, A P; Subramaniam, S; Hull, G; Lowerison, M W; Sajobi, T; Salluzzi, M; Wright, M R; Maxwell, M; Lacusta, S; Drupals, E; Armitage, K; Barber, P A; Smith, E E; Morrish, W F; Coutts, S B; Derdeyn, C; Demaerschalk, B; Yavagal, D; Martin, R; Brant, R; Yu, Y; Willinsky, R A; Montanera, W J; Weill, A; Kenney, C; Aram, H; Stewart, T; Stys, P K; Watson, T W; Klein, G; Pearson, D; Couillard, P; Trivedi, A; Singh, D; Klourfeld, E; Imoukhuede, O; Nikneshan, D; Blayney, S; Reddy, R; Choi, P; Horton, M; Musuka, T; Dubuc, V; Field, T S; Desai, J; Adatia, S; Alseraya, A; Nambiar, V; van Dijk, R; Wong, J H; Mitha, A P; Morrish, W F; Eesa, M; Newcommon, N J; Shuaib, A; Schwindt, B; Butcher, K S; Jeerakathil, T; Buck, B; Khan, K; Naik, S S; Emery, D J; Owen, R J; Kotylak, T B; Ashforth, R A; Yeo, T A; McNally, D; Siddiqui, M; Saqqur, M; Hussain, D; Kalashyan, H; Manosalva, A; Kate, M; Gioia, L; Hasan, S; Mohammad, A; Muratoglu, M; Williams, D; Thornton, J; Cullen, A; Brennan, P; O'Hare, A; Looby, S; Hyland, D; Duff, S; McCusker, M; Hallinan, B; Lee, S; McCormack, J; Moore, A; O'Connor, M; Donegan, C; Brewer, L; Martin, A; Murphy, S; O'Rourke, K; Smyth, S; Kelly, P; Lynch, T; Daly, T; O'Brien, P; O'Driscoll, A; Martin, M; Daly, T; Collins, R; Coughlan, T; McCabe, D; Murphy, S; O'Neill, D; Mulroy, M; Lynch, O; Walsh, T; O'Donnell, M; Galvin, T; Harbison, J; McElwaine, P; Mulpeter, K; McLoughlin, C; Reardon, M; Harkin, E; Dolan, E; Watts, M; Cunningham, N; Fallon, C; Gallagher, S; Cotter, P; Crowe, M; Doyle, R; Noone, I; Lapierre, M; Coté, V A; Lanthier, S; Odier, C; Durocher, A; Raymond, J; Weill, A; Daneault, N; Deschaintre, Y; Jankowitz, B; Baxendell, L; Massaro, L; Jackson-Graves, C; Decesare, S; Porter, P; Armbruster, K; Adams, A; Billigan, J; Oakley, J; Ducruet, A; Jadhav, A; Giurgiutiu, D-V; Aghaebrahim, A; Reddy, V; Hammer, M; Starr, M; Totoraitis, V; Wechsler, L; Streib, S; Rangaraju, S; Campbell, D; Rocha, M; Gulati, D; Silver, F L; Krings, T; Kalman, L; Cayley, A; Williams, J; Stewart, T; Wiegner, R; Casaubon, L K; Jaigobin, C; Del Campo, J M; Elamin, E; Schaafsma, J D; Willinsky, R A; Agid, R; Farb, R; Ter Brugge, K; Sapkoda, B L; Baxter, B W; Barton, K; Knox, A; Porter, A; Sirelkhatim, A; Devlin, T; Dellinger, C; Pitiyanuvath, N; Patterson, J; Nichols, J; Quarfordt, S; Calvert, J; Hawk, H; Fanale, C; Frei, D F; Bitner, A; Novak, A; Huddle, D; Bellon, R; Loy, D; Wagner, J; Chang, I; Lampe, E; Spencer, B; Pratt, R; Bartt, R; Shine, S; Dooley, G; Nguyen, T; Whaley, M; McCarthy, K; Teitelbaum, J; Tampieri, D; Poon, W; Campbell, N; Cortes, M; Dowlatshahi, D; Lum, C; Shamloul, R; Robert, S; Stotts, G; Shamy, M; Steffenhagen, N; Blacquiere, D; Hogan, M; AlHazzaa, M; Basir, G; Lesiuk, H; Iancu, D; Santos, M; Choe, H; Weisman, D C; Jonczak, K; Blue-Schaller, A; Shah, Q; MacKenzie, L; Klein, B; Kulandaivel, K; Kozak, O; Gzesh, D J; Harris, L J; Khoury, J S; Mandzia, J; Pelz, D; Crann, S; Fleming, L; Hesser, K; Beauchamp, B; Amato-Marzialli, B; Boulton, M; Lopez-Ojeda, P; Sharma, M; Lownie, S; Chan, R; Swartz, R; Howard, P; Golob, D; Gladstone, D; Boyle, K; Boulos, M; Hopyan, J; Yang, V; Da Costa, L; Holmstedt, C A; Turk, A S; Navarro, R; Jauch, E; Ozark, S; Turner, R; Phillips, S; Shankar, J; Jarrett, J; Gubitz, G; Maloney, W; Vandorpe, R; Schmidt, M; Heidenreich, J; Hunter, G; Kelly, M; Whelan, R; Peeling, L; Burns, P A; Hunter, A; Wiggam, I; Kerr, E; Watt, M; Fulton, A; Gordon, P; Rennie, I; Flynn, P; Smyth, G; O'Leary, S; Gentile, N; Linares, G; McNelis, P; Erkmen, K; Katz, P; Azizi, A; Weaver, M; Jungreis, C; Faro, S; Shah, P; Reimer, H; Kalugdan, V; Saposnik, G; Bharatha, A; Li, Y; Kostyrko, P; Santos, M; Marotta, T; Montanera, W; Sarma, D; Selchen, D; Spears, J; Heo, J H; Jeong, K; Kim, D J; Kim, B M; Kim, Y D; Song, D; Lee, K-J; Yoo, J; Bang, O Y; Rho, S; Lee, J; Jeon, P; Kim, K H; Cha, J; Kim, S J; Ryoo, S; Lee, M J; Sohn, S-I; Kim, C-H; Ryu, H-G; Hong, J-H; Chang, H-W; Lee, C-Y; Rha, J; Davis, Stephen M; Donnan, Geoffrey A; Campbell, Bruce Cv; Mitchell, Peter J; Churilov, Leonid; Yan, Bernard; Dowling, Richard; Yassi, Nawaf; Oxley, Thomas J; Wu, Teddy Y; Silver, Gabriel; McDonald, Amy; McCoy, Rachael; Kleinig, Timothy J; Scroop, Rebecca; Dewey, Helen M; Simpson, Marion; Brooks, Mark; Coulton, Bronwyn; Krause, Martin; Harrington, Timothy J; Steinfort, Brendan; Faulder, Kenneth; Priglinger, Miriam; Day, Susan; Phan, Thanh; Chong, Winston; Holt, Michael; Chandra, Ronil V; Ma, Henry; Young, Dennis; Wong, Kitty; Wijeratne, Tissa; Tu, Hans; Mackay, Elizabeth; Celestino, Sherisse; Bladin, Christopher F; Loh, Poh Sien; Gilligan, Amanda; Ross, Zofia; Coote, Skye; Frost, Tanya; Parsons, Mark W; Miteff, Ferdinand; Levi, Christopher R; Ang, Timothy; Spratt, Neil; Kaauwai, Lara; Badve, Monica; Rice, Henry; de Villiers, Laetitia; Barber, P Alan; McGuinness, Ben; Hope, Ayton; Moriarty, Maurice; Bennett, Patricia; Wong, Andrew; Coulthard, Alan; Lee, Andrew; Jannes, Jim; Field, Deborah; Sharma, Gagan; Salinas, Simon; Cowley, Elise; Snow, Barry; Kolbe, John; Stark, Richard; King, John; Macdonnell, Richard; Attia, John; D'Este, Cate; Saver, Jeffrey L; Goyal, Mayank; Diener, Hans-Christoph; Levy, Elad I; Bonafé, Alain; Mendes Pereira, Vitor; Jahan, Reza; Albers, Gregory W; Cognard, Christophe; Cohen, David J; Hacke, Werner; Jansen, Olav; Jovin, Tudor G; Mattle, Heinrich P; Nogueira, Raul G; Siddiqui, Adnan H; Yavagal, Dileep R; von Kummer, Rüdiger; Smith, Wade; Turjman, Francis; Hamilton, Scott; Chiacchierini, Richard; Amar, Arun; Sanossian, Nerses; Loh, Yince; Devlin, T; Baxter, B; Hawk, H; Sapkota, B; Quarfordt, S; Sirelkhatim, A; Dellinger, C; Barton, K; Reddy, V K; Ducruet, A; Jadhav, A; Horev, A; Giurgiutiu, D-V; Totoraitis, V; Hammer, M; Jankowitz, B; Wechsler, L; Rocha, M; Gulati, D; Campbell, D; Star, M; Baxendell, L; Oakley, J; Siddiqui, A; Hopkins, L N; Snyder, K; Sawyer, R; Hall, S; Costalat, V; Riquelme, C; Machi, P; Omer, E; Arquizan, C; Mourand, I; Charif, M; Ayrignac, X; Menjot de Champfleur, N; Leboucq, N; Gascou, G; Moynier, M; du Mesnil de Rochemont, R; Singer, O; Berkefeld, J; Foerch, C; Lorenz, M; Pfeilschifer, W; Hattingen, E; Wagner, M; You, S J; Lescher, S; Braun, H; Dehkharghani, S; Belagaje, S R; Anderson, A; Lima, A; Obideen, M; Haussen, D; Dharia, R; Frankel, M; Patel, V; Owada, K; Saad, A; Amerson, L; Horn, C; Doppelheuer, S; Schindler, K; Lopes, D K; Chen, M; Moftakhar, R; Anton, C; Smreczak, M; Carpenter, J S; Boo, S; Rai, A; Roberts, T; Tarabishy, A; Gutmann, L; Brooks, C; Brick, J; Domico, J; Reimann, G; Hinrichs, K; Becker, M; Heiss, E; Selle, C; Witteler, A; Al-Boutros, S; Danch, M-J; Ranft, A; Rohde, S; Burg, K; Weimar, C; Zegarac, V; Hartmann, C; Schlamann, M; Göricke, S; Ringlestein, A; Wanke, I; Mönninghoff, C; Dietzold, M; Budzik, R; Davis, T; Eubank, G; Hicks, W J; Pema, P; Vora, N; Mejilla, J; Taylor, M; Clark, W; Rontal, A; Fields, J; Peterson, B; Nesbit, G; Lutsep, H; Bozorgchami, H; Priest, R; Ologuntoye, O; Barnwell, S; Dogan, A; Herrick, K; Takahasi, C; Beadell, N; Brown, B; Jamieson, S; Hussain, M S; Russman, A; Hui, F; Wisco, D; Uchino, K; Khawaja, Z; Katzan, I; Toth, G; Cheng-Ching, E; Bain, M; Man, S; Farrag, A; George, P; John, S; Shankar, L; Drofa, A; Dahlgren, R; Bauer, A; Itreat, A; Taqui, A; Cerejo, R; Richmond, A; Ringleb, P; Bendszus, M; Möhlenbruch, M; Reiff, T; Amiri, H; Purrucker, J; Herweh, C; Pham, M; Menn, O; Ludwig, I; Acosta, I; Villar, C; Morgan, W; Sombutmai, C; Hellinger, F; Allen, E; Bellew, M; Gandhi, R; Bonwit, E; Aly, J; Ecker, R D; Seder, D; Morris, J; Skaletsky, M; Belden, J; Baker, C; Connolly, L S; Papanagiotou, P; Roth, C; Kastrup, A; Politi, M; Brunner, F; Alexandrou, M; Merdivan, H; Ramsey, C; Given Ii, C; Renfrow, S; Deshmukh, V; Sasadeusz, K; Vincent, F; Thiesing, J T; Putnam, J; Bhatt, A; Kansara, A; Caceves, D; Lowenkopf, T; Yanase, L; Zurasky, J; Dancer, S; Freeman, B; Scheibe-Mirek, T; Robison, J; Rontal, A; Roll, J; Clark, D; Rodriguez, M; Fitzsimmons, B-Fm; Zaidat, O; Lynch, J R; Lazzaro, M; Larson, T; Padmore, L; Das, E; Farrow-Schmidt, A; Hassan, A; Tekle, W; Cate, C; Jansen, O; Cnyrim, C; Wodarg, F; Wiese, C; Binder, A; Riedel, C; Rohr, A; Lang, N; Laufs, H; Krieter, S; Remonda, L; Diepers, M; Añon, J; Nedeltchev, K; Kahles, T; Biethahn, S; Lindner, M; Chang, V; Gächter, C; Esperon, C; Guglielmetti, M; Arenillas Lara, J F; Martínez Galdámez, M; Calleja Sanz, A I; Cortijo Garcia, E; Garcia Bermejo, P; Perez, S; Mulero Carrillo, P; Crespo Vallejo, E; Ruiz Piñero, M; Lopez Mesonero, L; Reyes Muñoz, F J; Brekenfeld, C; Buhk, J-H; Krützelmann, A; Thomalla, G; Cheng, B; Beck, C; Hoppe, J; Goebell, E; Holst, B; Grzyska, U; Wortmann, G; Starkman, S; Duckwiler, G; Jahan, R; Rao, N; Sheth, S; Ng, K; Noorian, A; Szeder, V; Nour, M; McManus, M; Huang, J; Tarpley, J; Tateshima, S; Gonzalez, N; Ali, L; Liebeskind, D; Hinman, J; Calderon-Arnulphi, M; Liang, C; Guzy, J; Koch, S; DeSousa, K; Gordon-Perue, G; Haussen, D; Elhammady, M; Peterson, E; Pandey, V; Dharmadhikari, S; Khandelwal, P; Malik, A; Pafford, R; Gonzalez, P; Ramdas, K; Andersen, G; Damgaard, D; Von Weitzel-Mudersbach, P; Simonsen, C; Ruiz de Morales Ayudarte, N; Poulsen, M; Sørensen, L; Karabegovich, S; Hjørringgaard, M; Hjort, N; Harbo, T; Sørensen, K; Deshaies, E; Padalino, D; Swarnkar, A; Latorre, J G; Elnour, E; El-Zammar, Z; Villwock, M; Farid, H; Balgude, A; Cross, L; Hansen, K; Holtmannspötter, M; Kondziella, D; Hoejgaard, J; Taudorf, S; Soendergaard, H; Wagner, A; Cronquist, M; Stavngaard, T; Cortsen, M; Krarup, L H; Hyldal, T; Haring, H-P; Guggenberger, S; Hamberger, M; Trenkler, J; Sonnberger, M; Nussbaumer, K; Dominger, C; Bach, E; Jagadeesan, B D; Taylor, R; Kim, J; Shea, K; Tummala, R; Zacharatos, H; Sandhu, D; Ezzeddine, M; Grande, A; Hildebrandt, D; Miller, K; Scherber, J; Hendrickson, A; Jumaa, M; Zaidi, S; Hendrickson, T; Snyder, V; Killer-Oberpfalzer, M; Mutzenbach, J; Weymayr, F; Broussalis, E; Stadler, K; Jedlitschka, A; Malek, A; Mueller-Kronast, N; Beck, P; Martin, C; Summers, D; Day, J; Bettinger, I; Holloway, W; Olds, K; Arkin, S; Akhtar, N; Boutwell, C; Crandall, S; Schwartzman, M; Weinstein, C; Brion, B; Prothmann, S; Kleine, J; Kreiser, K; Boeckh-Behrens, T; Poppert, H; Wunderlich, S; Koch, M L; Biberacher, V; Huberle, A; Gora-Stahlberg, G; Knier, B; Meindl, T; Utpadel-Fischler, D; Zech, M; Kowarik, M; Seifert, C; Schwaiger, B; Puri, A; Hou, S; Wakhloo, A; Moonis, M; Henninger, N; Goddeau, R; Massari, F; Minaeian, A; Lozano, J D; Ramzan, M; Stout, C; Patel, A; Tunguturi, A; Onteddu, S; Carandang, R; Howk, M; Ribó, M; Sanjuan, E; Rubiera, M; Pagola, J; Flores, A; Muchada, M; Meler, P; Huerga, E; Gelabert, S; Coscojuela, P; Tomasello, A; Rodriguez, D; Santamarina, E; Maisterra, O; Boned, S; Seró, L; Rovira, A; Molina, C A; Millán, M; Muñoz, L; Pérez de la Ossa, N; Gomis, M; Dorado, L; López-Cancio, E; Palomeras, E; Munuera, J; García Bermejo, P; Remollo, S; Castaño, C; García-Sort, R; Cuadras, P; Puyalto, P; Hernández-Pérez, M; Jiménez, M; Martínez-Piñeiro, A; Lucente, G; Dávalos, A; Chamorro, A; Urra, X; Obach, V; Cervera, A; Amaro, S; Llull, L; Codas, J; Balasa, M; Navarro, J; Ariño, H; Aceituno, A; Rudilosso, S; Renu, A; Macho, J M; San Roman, L; Blasco, J; López, A; Macías, N; Cardona, P; Quesada, H; Rubio, F; Cano, L; Lara, B; de Miquel, M A; Aja, L; Serena, J; Cobo, E; Albers, Gregory W; Lees, Kennedy R; Arenillas, J; Roberts, R; Minhas, P; Al-Ajlan, F; Salluzzi, M; Zimmel, L; Patel, S; Eesa, M; Martí-Fàbregas, J; Jankowitz, B; Serena, J; Salvat-Plana, M; López-Cancio, E; Bracard, S; Ducrocq, Xavier; Anxionnat, René; Baillot, Pierre-Alexandre; Barbier, Charlotte; Derelle, Anne-Laure; Lacour, Jean-Christophe; Richard, Sébastien; Samson, Yves; Sourour, Nader; Baronnet-Chauvet, Flore; Clarencon, Frédéric; Crozier, Sophie; Deltour, Sandrine; Di Maria, Federico; Le Bouc, Raphael; Leger, Anne; Mutlu, Gurkan; Rosso, Charlotte; Szatmary, Zoltan; Yger, Marion; Zavanone, Chiara; Bakchine, Serge; Pierot, Laurent; Caucheteux, Nathalie; Estrade, Laurent; Kadziolka, Krzysztof; Leautaud, Alexandre; Renkes, Céline; Serre, Isabelle; Desal, Hubert; Guillon, Benoît; Boutoleau-Bretonniere, Claire; Daumas-Duport, Benjamin; De Gaalon, Solène; Derkinderen, Pascal; Evain, Sarah; Herisson, Fanny; Laplaud, David-Axel; Lebouvier, Thibaud; Lintia-Gaultier, Alina; Pouclet-Courtemanche, Hélène; Rouaud, Tiphaine; Rouaud Jaffrenou, Violaine; Schunck, Aurélia; Sevin-Allouet, Mathieu; Toulgoat, Frederique; Wiertlewski, Sandrine; Gauvrit, Jean-Yves; Ronziere, Thomas; Cahagne, Vincent; Ferre, Jean-Christophe; Pinel, Jean-François; Raoult, Hélène; Mas, Jean-Louis; Meder, Jean-François; Al Najjar-Carpentier, Amen-Adam; Birchenall, Julia; Bodiguel, Eric; Calvet, David; Domigo, Valérie; Godon-Hardy, Sylvie; Guiraud, Vincent; Lamy, Catherine; Majhadi, Loubna; Morin, Ludovic; Naggara, Olivier; Trystram, Denis; Turc, Guillaume; Berge, Jérôme; Sibon, Igor; Menegon, Patrice; Barreau, Xavier; Rouanet, François; Debruxelles, Sabrina; Kazadi, Annabelle; Renou, Pauline; Fleury, Olivier; Pasco-Papon, Anne; Dubas, Frédéric; Caroff, Jildaz; Godard Ducceschi, Sophie; Hamon, Marie-Aurélie; Lecluse, Alderic; Marc, Guillaume; Giroud, Maurice; Ricolfi, Frédéric; Bejot, Yannick; Chavent, Adrien; Gentil, Arnaud; Kazemi, Apolline; Osseby, Guy-Victor; Voguet, Charlotte; Mahagne, Marie-Hélène; Sedat, Jacques; Chau, Yves; Suissa, Laurent; Lachaud, Sylvain; Houdart, Emmanuel; Stapf, Christian; Buffon Porcher, Frédérique; Chabriat, Hugues; Guedin, Pierre; Herve, Dominique; Jouvent, Eric; Mawet, Jérôme; Saint-Maurice, Jean-Pierre; Schneble, Hans-Martin; Turjman, Francis; Nighoghossian, Norbert; Berhoune, Nadia-Nawel; Bouhour, Françoise; Cho, Tae-Hee; Derex, Laurent; Felix, Sandra; Gervais-Bernard, Hélène; Gory, Benjamin; Manera, Luis; Mechtouff, Laura; Ritzenthaler, Thomas; Riva, Roberto; Salaris Silvio, Fabrizio; Tilikete, Caroline; Blanc, Raphael; Obadia, Michaël; Bartolini, Mario Bruno; Gueguen, Antoine; Piotin, Michel; Pistocchi, Silvia; Redjem, Hocine; Drouineau, Jacques; Neau, Jean-Philippe; Godeneche, Gaelle; Lamy, Matthias; Marsac, Emilia; Velasco, Stephane; Clavelou, Pierre; Chabert, Emmanuel; Bourgois, Nathalie; Cornut-Chauvinc, Catherine; Ferrier, Anna; Gabrillargues, Jean; Jean, Betty; Marques, Anna-Raquel; Vitello, Nicolas; Detante, Olivier; Barbieux, Marianne; Boubagra, Kamel; Favre Wiki, Isabelle; Garambois, Katia; Tahon, Florence; Ashok, Vasdev; Voguet, Charlotte; Coskun, Oguzhan; Guedin, Pierre; Rodesch, Georges; Lapergue, Bertrand; Bourdain, Frédéric; Evrard, Serge; Graveleau, Philippe; Decroix, Jean Pierre; Wang, Adrien; Sellal, François; Ahle, Guido; Carelli, Gabriela; Dugay, Marie-Hélène; Gaultier, Claude; Lebedinsky, Ariel Pablo; Lita, Lavinia; Musacchio, Raul Mariano; Renglewicz-Destuynder, Catherine; Tournade, Alain; Vuillemet, Françis; Montoro, Francisco Macian; Mounayer, Charbel; Faugeras, Frederic; Gimenez, Laetitia; Labach, Catherine; Lautrette, Géraldine; Denier, Christian; Saliou, Guillaume; Chassin, Olivier; Dussaule, Claire; Melki, Elsa; Ozanne, Augustin; Puccinelli, Francesco; Sachet, Marina; Sarov, Mariana; Bonneville, Jean-François; Moulin, Thierry; Biondi, Alessandra; De Bustos Medeiros, Elisabeth; Vuillier, Fabrice; Courtheoux, Patrick; Viader, Fausto; Apoil-Brissard, Marion; Bataille, Mathieu; Bonnet, Anne-Laure; Cogez, Julien; Kazemi, Apolline; Touze, Emmanuel; Leclerc, Xavier; Leys, Didier; Aggour, Mohamed; Aguettaz, Pierre; Bodenant, Marie; Cordonnier, Charlotte; Deplanque, Dominique; Girot, Marie; Henon, Hilde; Kalsoum, Erwah; Lucas, Christian; Pruvo, Jean-Pierre; Zuniga, Paolo; Bonafé, Alain; Arquizan, Caroline; Costalat, Vincent; Machi, Paolo; Mourand, Isabelle; Riquelme, Carlos; Bounolleau, Pierre; Arteaga, Charles; Faivre, Anthony; Bintner, Marc; Tournebize, Patrice; Charlin, Cyril; Darcel, Françoise; Gauthier-Lasalarie, Pascale; Jeremenko, Marcia; Mouton, Servane; Zerlauth, Jean-Baptiste; Lamy, Chantal; Hervé, Deramond; Hassan, Hosseini; Gaston, André; Barral, Francis-Guy; Garnier, Pierre; Beaujeux, Rémy; Wolff, Valérie; Herbreteau, Denis; Debiais, Séverine; Murray, Alicia; Ford, Gary; Muir, Keith W; White, Philip; Clifton, Andy; Freeman, Janet; Ford, Ian; Markus, Hugh; Wardlaw, Joanna; Lees, Kennedy R; Molyneux, Andy; Robinson, Thompson; Lewis, Steff; Norrie, John; Robertson, Fergus; Perry, Richard; Dixit, Anand; Cloud, Geoffrey; Clifton, Andrew; Madigan, Jeremy; Roffe, Christine; Nayak, Sanjeev; Lobotesis, Kyriakos; Smith, Craig; Herwadkar, Amit; Kandasamy, Naga; Goddard, Tony; Bamford, John; Subramanian, Ganesh; Lenthall, Rob; Littleton, Edward; Lamin, Sal; Storey, Kelley; Ghatala, Rita; Banaras, Azra; Aeron-Thomas, John; Hazel, Bath; Maguire, Holly; Veraque, Emelda; Harrison, Louise; Keshvara, Rekha; Cunningham, James
BACKGROUND:CT perfusion (CTP) and diffusion or perfusion MRI might assist patient selection for endovascular thrombectomy. We aimed to establish whether imaging assessments of irreversibly injured ischaemic core and potentially salvageable penumbra volumes were associated with functional outcome and whether they interacted with the treatment effect of endovascular thrombectomy on functional outcome. METHODS:/s. Critically hypoperfused tissue was estimated as the volume of tissue with a CTP time to maximum longer than 6 s. Mismatch volume (ie, the estimated penumbral volume) was calculated as critically hypoperfused tissue volume minus ischaemic core volume. The association of ischaemic core and penumbral volumes with 90-day mRS score was analysed with multivariable logistic regression (functional independence, defined as mRS score 0-2) and ordinal logistic regression (functional improvement by at least one mRS category) in all patients and in a subset of those with more than 50% endovascular reperfusion, adjusted for baseline prognostic variables. The meta-analysis was prospectively designed by the HERMES executive committee, but not registered. FINDINGS:=0·94). Mismatch volume, examined only in the CTP group because of the small numbers of patients who had perfusion MRI, was not associated with either functional independence or functional improvement. In patients with CTP with more than 50% endovascular reperfusion (n=186), age, ischaemic core volume, and imaging-to-reperfusion time were independently associated with functional improvement. Risk of bias between studies was generally low. INTERPRETATION:Estimated ischaemic core volume was independently associated with functional independence and functional improvement but did not modify the treatment benefit of endovascular thrombectomy over standard medical therapy for improved functional outcome. Combining ischaemic core volume with age and expected imaging-to-reperfusion time will improve assessment of prognosis and might inform endovascular thrombectomy treatment decisions. FUNDING:Medtronic.
PMID: 30413385
ISSN: 1474-4465
CID: 5121972

Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data

Román, Luis San; Menon, Bijoy K; Blasco, Jordi; Hernández-Pérez, María; Dávalos, Antoni; Majoie, Charles B L M; Campbell, Bruce C V; Guillemin, Francis; Lingsma, Hester; Anxionnat, René; Epstein, Jonathan; Saver, Jeffrey L; Marquering, Henk; Wong, John H; Lopes, Demetrius; Reimann, Gernot; Desal, Hubert; Dippel, Diederik W J; Coutts, Shelagh; du Mesnil de Rochemont, Richard; Yavagal, Dileep; Ferre, Jean Christophe; Roos, Yvo B W E M; Liebeskind, David S; Lenthall, Robert; Molina, Carlos; Al Ajlan, Fahad S; Reddy, Vivek; Dowlatshahi, Dar; Sourour, Nader-Antoine; Oppenheim, Catherine; Mitha, Alim P; Davis, Stephen M; Weimar, Christian; van Oostenbrugge, Robert J; Cobo, Erik; Kleinig, Timothy J; Donnan, Geoffrey A; van der Lugt, Aad; Demchuk, Andrew M; Berkhemer, Olvert A; Boers, Anna M M; Ford, Gary A; Muir, Keith W; Brown, B Scott; Jovin, Tudor; van Zwam, Wim H; Mitchell, Peter J; Hill, Michael D; White, Phil; Bracard, Serge; Goyal, Mayank; Berkhemer, Olvert A; Fransen, Puck Ss; Beumer, Debbie; 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BACKGROUND:Evidence regarding whether imaging can be used effectively to select patients for endovascular thrombectomy (EVT) is scarce. We aimed to investigate the association between baseline imaging features and safety and efficacy of EVT in acute ischaemic stroke caused by anterior large-vessel occlusion. METHODS:In this meta-analysis of individual patient-level data, the HERMES collaboration identified in PubMed seven randomised trials in endovascular stroke that compared EVT with standard medical therapy, published between Jan 1, 2010, and Oct 31, 2017. Only trials that required vessel imaging to identify patients with proximal anterior circulation ischaemic stroke and that used predominantly stent retrievers or second-generation neurothrombectomy devices in the EVT group were included. Risk of bias was assessed with the Cochrane handbook methodology. Central investigators, masked to clinical information other than stroke side, categorised baseline imaging features of ischaemic change with the Alberta Stroke Program Early CT Score (ASPECTS) or according to involvement of more than 33% of middle cerebral artery territory, and by thrombus volume, hyperdensity, and collateral status. The primary endpoint was neurological functional disability scored on the modified Rankin Scale (mRS) score at 90 days after randomisation. Safety outcomes included symptomatic intracranial haemorrhage, parenchymal haematoma type 2 within 5 days of randomisation, and mortality within 90 days. For the primary analysis, we used mixed-methods ordinal logistic regression adjusted for age, sex, National Institutes of Health Stroke Scale score at admission, intravenous alteplase, and time from onset to randomisation, and we used interaction terms to test whether imaging categorisation at baseline modifies the association between treatment and outcome. This meta-analysis was prospectively designed by the HERMES executive committee but has not been registered. FINDINGS:=0·012). INTERPRETATION:EVT achieves better outcomes at 90 days than standard medical therapy across a broad range of baseline imaging categories, including infarcts affecting more than 33% of middle cerebral artery territory or ASPECTS less than 6, although in these patients the risk of symptomatic intracranial haemorrhage was higher in the EVT group than the control group. This analysis provides preliminary evidence for potential use of EVT in patients with large infarcts at baseline. FUNDING:Medtronic.
PMID: 30264728
ISSN: 1474-4465
CID: 5121962

Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data

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Barnwell, S; Dogan, A; Herrick, K; Takahasi, C; Beadell, N; Brown, B; Jamieson, S; Hussain, M S; Russman, A; Hui, F; Wisco, D; Uchino, K; Khawaja, Z; Katzan, I; Toth, G; Cheng-Ching, E; Bain, M; Man, S; Farrag, A; George, P; John, S; Shankar, L; Drofa, A; Dahlgren, R; Bauer, A; Itreat, A; Taqui, A; Cerejo, R; Richmond, A; Ringleb, P; Bendszus, M; Möhlenbruch, M; Reiff, T; Amiri, H; Purrucker, J; Herweh, C; Pham, M; Menn, O; Ludwig, I; Acosta, I; Villar, C; Morgan, W; Sombutmai, C; Hellinger, F; Allen, E; Bellew, M; Gandhi, R; Bonwit, E; Aly, J; Ecker, R D; Seder, D; Morris, J; Skaletsky, M; Belden, J; Baker, C; Connolly, L S; Papanagiotou, P; Roth, C; Kastrup, A; Politi, M; Brunner, F; Alexandrou, M; Merdivan, H; Ramsey, C; Given Ii, C; Renfrow, S; Deshmukh, V; Sasadeusz, K; Vincent, F; Thiesing, J T; Putnam, J; Bhatt, A; Kansara, A; Caceves, D; Lowenkopf, T; Yanase, L; Zurasky, J; Dancer, S; Freeman, B; Scheibe-Mirek, T; Robison, J; Rontal, A; Roll, J; Clark, D; Rodriguez, M; Fitzsimmons, B-Fm; Zaidat, O; Lynch, J R; Lazzaro, M; Larson, T; Padmore, L; Das, E; Farrow-Schmidt, A; Hassan, A; Tekle, W; Cate, C; Jansen, O; Cnyrim, C; Wodarg, F; Wiese, C; Binder, A; Riedel, C; Rohr, A; Lang, N; Laufs, H; Krieter, S; Remonda, L; Diepers, M; Añon, J; Nedeltchev, K; Kahles, T; Biethahn, S; Lindner, M; Chang, V; Gächter, C; Esperon, C; Guglielmetti, M; Arenillas Lara, J F; Martínez Galdámez, M; Calleja Sanz, A I; Cortijo Garcia, E; Garcia Bermejo, P; Perez, S; Mulero Carrillo, P; Crespo Vallejo, E; Ruiz Piñero, M; Lopez Mesonero, L; Reyes Muñoz, F J; Brekenfeld, C; Buhk, J-H; Krützelmann, A; Thomalla, G; Cheng, B; Beck, C; Hoppe, J; Goebell, E; Holst, B; Grzyska, U; Wortmann, G; Starkman, S; Duckwiler, G; Jahan, R; Rao, N; Sheth, S; Ng, K; Noorian, A; Szeder, V; Nour, M; McManus, M; Huang, J; Tarpley, J; Tateshima, S; Gonzalez, N; Ali, L; Liebeskind, D; Hinman, J; Calderon-Arnulphi, M; Liang, C; Guzy, J; Koch, S; DeSousa, K; Gordon-Perue, G; Haussen, D; Elhammady, M; Peterson, E; Pandey, V; Dharmadhikari, S; Khandelwal, P; Malik, A; Pafford, R; Gonzalez, P; Ramdas, K; Andersen, G; Damgaard, D; Von Weitzel-Mudersbach, P; Simonsen, C; Ruiz de Morales Ayudarte, N; Poulsen, M; Sørensen, L; Karabegovich, S; Hjørringgaard, M; Hjort, N; Harbo, T; Sørensen, K; Deshaies, E; Padalino, D; Swarnkar, A; Latorre, J G; Elnour, E; El-Zammar, Z; Villwock, M; Farid, H; Balgude, A; Cross, L; Hansen, K; Holtmannspötter, M; Kondziella, D; Hoejgaard, J; Taudorf, S; Soendergaard, H; Wagner, A; Cronquist, M; Stavngaard, T; Cortsen, M; Krarup, L H; Hyldal, T; Haring, H-P; Guggenberger, S; Hamberger, M; Trenkler, J; Sonnberger, M; Nussbaumer, K; Dominger, C; Bach, E; Jagadeesan, B D; Taylor, R; Kim, J; Shea, K; Tummala, R; Zacharatos, H; Sandhu, D; Ezzeddine, M; Grande, A; Hildebrandt, D; Miller, K; Scherber, J; Hendrickson, A; Jumaa, M; Zaidi, S; Hendrickson, T; Snyder, V; Killer-Oberpfalzer, M; Mutzenbach, J; Weymayr, F; Broussalis, E; Stadler, K; Jedlitschka, A; Malek, A; Mueller-Kronast, N; Beck, P; Martin, C; Summers, D; Day, J; Bettinger, I; Holloway, W; Olds, K; Arkin, S; Akhtar, N; Boutwell, C; Crandall, S; Schwartzman, M; Weinstein, C; Brion, B; Prothmann, S; Kleine, J; Kreiser, K; Boeckh-Behrens, T; Poppert, H; Wunderlich, S; Koch, M L; Biberacher, V; Huberle, A; Gora-Stahlberg, G; Knier, B; Meindl, T; Utpadel-Fischler, D; Zech, M; Kowarik, M; Seifert, C; Schwaiger, B; Puri, A; Hou, S; Wakhloo, A; Moonis, M; Henninger, N; Goddeau, R; Massari, F; Minaeian, A; Lozano, J D; Ramzan, M; Stout, C; Patel, A; Tunguturi, A; Onteddu, S; Carandang, R; Howk, M; Ribó, M; Sanjuan, E; Rubiera, M; Pagola, J; Flores, A; Muchada, M; Meler, P; Huerga, E; Gelabert, S; Coscojuela, P; Tomasello, A; Rodriguez, D; Santamarina, E; Maisterra, O; Boned, S; Seró, L; Rovira, A; Molina, C A; Millán, M; Muñoz, L; Pérez de la Ossa, N; Gomis, M; Dorado, L; López-Cancio, E; Palomeras, E; Munuera, J; García Bermejo, P; Remollo, S; Castaño, C; García-Sort, R; Cuadras, P; Puyalto, P; Hernández-Pérez, M; Jiménez, M; Martínez-Piñeiro, A; Lucente, G; Dávalos, A; Chamorro, A; Urra, X; Obach, V; Cervera, A; Amaro, S; Llull, L; Codas, J; Balasa, M; Navarro, J; Ariño, H; Aceituno, A; Rudilosso, S; Renu, A; Macho, J M; San Roman, L; Blasco, J; López, A; Macías, N; Cardona, P; Quesada, H; Rubio, F; Cano, L; Lara, B; de Miquel, M A; Aja, L; Serena, J; Cobo, E; Albers, Gregory W; Lees, Kennedy R; Arenillas, J; Roberts, R; Minhas, P; Al-Ajlan, F; Salluzzi, M; Zimmel, L; Patel, S; Eesa, M; Martí-Fàbregas, J; Jankowitz, B; Serena, J; Salvat-Plana, M; López-Cancio, E; Bracard, S; Ducrocq, Xavier; Anxionnat, René; Baillot, Pierre-Alexandre; Barbier, Charlotte; Derelle, Anne-Laure; Lacour, Jean-Christophe; Richard, Sébastien; Samson, Yves; Sourour, Nader; Baronnet-Chauvet, Flore; Clarencon, Frédéric; Crozier, Sophie; Deltour, Sandrine; Di Maria, Federico; Le Bouc, Raphael; Leger, Anne; Mutlu, Gurkan; Rosso, Charlotte; Szatmary, Zoltan; Yger, Marion; Zavanone, Chiara; Bakchine, Serge; Pierot, Laurent; Caucheteux, Nathalie; Estrade, Laurent; Kadziolka, Krzysztof; Leautaud, Alexandre; Renkes, Céline; Serre, Isabelle; Desal, Hubert; Guillon, Benoît; Boutoleau-Bretonniere, Claire; Daumas-Duport, Benjamin; De Gaalon, Solène; Derkinderen, Pascal; Evain, Sarah; Herisson, Fanny; Laplaud, David-Axel; Lebouvier, Thibaud; Lintia-Gaultier, Alina; Pouclet-Courtemanche, Hélène; Rouaud, Tiphaine; Rouaud Jaffrenou, Violaine; Schunck, Aurélia; Sevin-Allouet, Mathieu; Toulgoat, Frederique; Wiertlewski, Sandrine; Gauvrit, Jean-Yves; Ronziere, Thomas; Cahagne, Vincent; Ferre, Jean-Christophe; Pinel, Jean-François; Raoult, Hélène; Mas, Jean-Louis; Meder, Jean-François; Al Najjar-Carpentier, Amen-Adam; Birchenall, Julia; Bodiguel, Eric; Calvet, David; Domigo, Valérie; Godon-Hardy, Sylvie; Guiraud, Vincent; Lamy, Catherine; Majhadi, Loubna; Morin, Ludovic; Naggara, Olivier; Trystram, Denis; Turc, Guillaume; Berge, Jérôme; Sibon, Igor; Menegon, Patrice; Barreau, Xavier; Rouanet, François; Debruxelles, Sabrina; Kazadi, Annabelle; Renou, Pauline; Fleury, Olivier; Pasco-Papon, Anne; Dubas, Frédéric; Caroff, Jildaz; Godard Ducceschi, Sophie; Hamon, Marie-Aurélie; Lecluse, Alderic; Marc, Guillaume; Giroud, Maurice; Ricolfi, Frédéric; Bejot, Yannick; Chavent, Adrien; Gentil, Arnaud; Kazemi, Apolline; Osseby, Guy-Victor; Voguet, Charlotte; Mahagne, Marie-Hélène; Sedat, Jacques; Chau, Yves; Suissa, Laurent; Lachaud, Sylvain; Houdart, Emmanuel; Stapf, Christian; Buffon Porcher, Frédérique; Chabriat, Hugues; Guedin, Pierre; Herve, Dominique; Jouvent, Eric; Mawet, Jérôme; Saint-Maurice, Jean-Pierre; Schneble, Hans-Martin; Turjman, Francis; Nighoghossian, Norbert; Berhoune, Nadia-Nawel; Bouhour, Françoise; Cho, Tae-Hee; Derex, Laurent; Felix, Sandra; Gervais-Bernard, Hélène; Gory, Benjamin; Manera, Luis; Mechtouff, Laura; Ritzenthaler, Thomas; Riva, Roberto; Salaris Silvio, Fabrizio; Tilikete, Caroline; Blanc, Raphael; Obadia, Michaël; Bartolini, Mario Bruno; Gueguen, Antoine; Piotin, Michel; Pistocchi, Silvia; Redjem, Hocine; Drouineau, Jacques; Neau, Jean-Philippe; Godeneche, Gaelle; Lamy, Matthias; Marsac, Emilia; Velasco, Stephane; Clavelou, Pierre; Chabert, Emmanuel; Bourgois, Nathalie; Cornut-Chauvinc, Catherine; Ferrier, Anna; Gabrillargues, Jean; Jean, Betty; Marques, Anna-Raquel; Vitello, Nicolas; Detante, Olivier; Barbieux, Marianne; Boubagra, Kamel; Favre Wiki, Isabelle; Garambois, Katia; Tahon, Florence; Ashok, Vasdev; Voguet, Charlotte; Coskun, Oguzhan; Guedin, Pierre; Rodesch, Georges; Lapergue, Bertrand; Bourdain, Frédéric; Evrard, Serge; Graveleau, Philippe; Decroix, Jean Pierre; Wang, Adrien; Sellal, François; Ahle, Guido; Carelli, Gabriela; Dugay, Marie-Hélène; Gaultier, Claude; Lebedinsky, Ariel Pablo; Lita, Lavinia; Musacchio, Raul Mariano; Renglewicz-Destuynder, Catherine; Tournade, Alain; Vuillemet, Françis; Montoro, Francisco Macian; Mounayer, Charbel; Faugeras, Frederic; Gimenez, Laetitia; Labach, Catherine; Lautrette, Géraldine; Denier, Christian; Saliou, Guillaume; Chassin, Olivier; Dussaule, Claire; Melki, Elsa; Ozanne, Augustin; Puccinelli, Francesco; Sachet, Marina; Sarov, Mariana; Bonneville, Jean-François; Moulin, Thierry; Biondi, Alessandra; De Bustos Medeiros, Elisabeth; Vuillier, Fabrice; Courtheoux, Patrick; Viader, Fausto; Apoil-Brissard, Marion; Bataille, Mathieu; Bonnet, Anne-Laure; Cogez, Julien; Kazemi, Apolline; Touze, Emmanuel; Leclerc, Xavier; Leys, Didier; Aggour, Mohamed; Aguettaz, Pierre; Bodenant, Marie; Cordonnier, Charlotte; Deplanque, Dominique; Girot, Marie; Henon, Hilde; Kalsoum, Erwah; Lucas, Christian; Pruvo, Jean-Pierre; Zuniga, Paolo; Bonafé, Alain; Arquizan, Caroline; Costalat, Vincent; Machi, Paolo; Mourand, Isabelle; Riquelme, Carlos; Bounolleau, Pierre; Arteaga, Charles; Faivre, Anthony; Bintner, Marc; Tournebize, Patrice; Charlin, Cyril; Darcel, Françoise; Gauthier-Lasalarie, Pascale; Jeremenko, Marcia; Mouton, Servane; Zerlauth, Jean-Baptiste; Lamy, Chantal; Hervé, Deramond; Hassan, Hosseini; Gaston, André; Barral, Francis-Guy; Garnier, Pierre; Beaujeux, Rémy; Wolff, Valérie; Herbreteau, Denis; Debiais, Séverine; Murray, Alicia; Ford, Gary; Muir, Keith W; White, Philip; Brown, Martin M; Clifton, Andy; Freeman, Janet; Ford, Ian; Markus, Hugh; Wardlaw, Joanna; Lees, Kennedy R; Molyneux, Andy; Robinson, Thompson; Lewis, Steff; Norrie, John; Robertson, Fergus; Perry, Richard; Dixit, Anand; Cloud, Geoffrey; Clifton, Andrew; Madigan, Jeremy; Roffe, Christine; Nayak, Sanjeev; Lobotesis, Kyriakos; Smith, Craig; Herwadkar, Amit; Kandasamy, Naga; Goddard, Tony; Bamford, John; Subramanian, Ganesh; Lenthall, Rob; Littleton, Edward; Lamin, Sal; Storey, Kelley; Ghatala, Rita; Banaras, Azra; Aeron-Thomas, John; Hazel, Bath; Maguire, Holly; Veraque, Emelda; Harrison, Louise; Keshvara, Rekha; Cunningham, James
BACKGROUND:General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. METHODS:For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. FINDINGS:Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09-2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75-3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14-2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. INTERPRETATION:Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons. FUNDING:Medtronic.
PMID: 29263006
ISSN: 1474-4465
CID: 5121942

The Association of Team-Specific Workload and Staffing with Odds of Burnout Among VA Primary Care Team Members

Helfrich, Christian D; Simonetti, Joseph A; Clinton, Walter L; Wood, Gordon B; Taylor, Leslie; Schectman, Gordon; Stark, Richard; Rubenstein, Lisa V; Fihn, Stephan D; Nelson, Karin M
BACKGROUND:Work-related burnout is common in primary care and is associated with worse patient safety, patient satisfaction, and employee mental health. Workload, staffing stability, and team completeness may be drivers of burnout. However, few studies have assessed these associations at the team level, and fewer still include members of the team beyond physicians. OBJECTIVE:To study the associations of burnout among primary care providers (PCPs), nurse care managers, clinical associates (MAs, LPNs), and administrative clerks with the staffing and workload on their teams. DESIGN/METHODS:We conducted an individual-level cross-sectional analysis of survey and administrative data in 2014. PARTICIPANTS/METHODS:Primary care personnel at VA clinics responding to a national survey. MAIN MEASURES/METHODS:Burnout was measured with a validated single-item survey measure dichotomized to indicate the presence of burnout. The independent variables were survey measures of team staffing (having a fully staffed team, serving on multiple teams, and turnover on the team), and workload both from survey items (working extended hours), and administrative data (patient panel overcapacity and average panel comorbidity). KEY RESULTS/RESULTS:There were 4610 respondents (estimated response rate of 20.9%). The overall prevalence of burnout was 41%. In adjusted analyses, the strongest associations with burnout were having a fully staffed team (odds ratio [OR] = 0.55, 95% CI 0.47-0.65), having turnover on the team (OR = 1.67, 95% CI 1.43-1.94), and having patient panel overcapacity (OR = 1.19, 95% CI 1.01-1.40). The observed burnout prevalence was 30.1% lower (28.5% vs. 58.6%) for respondents working on fully staffed teams with no turnover and caring for a panel within capacity, relative to respondents in the inverse condition. CONCLUSIONS:Complete team staffing, turnover among team members, and panel overcapacity had strong, cumulative associations with burnout. Further research is needed to understand whether improvements in these factors would lower burnout.
PMCID:5481228
PMID: 28233221
ISSN: 1525-1497
CID: 3078922

Early changes in VA medical home components and utilization

Yoon, Jean; Liu, Chuan-Fen; Lo, Jeanie; Schectman, Gordon; Stark, Richard; Rubenstein, Lisa V; Yano, Elizabeth M
OBJECTIVES/OBJECTIVE:In 2010, the Veterans Health Administration (VA) began national implementation of its patient-centered medical home (PCMH) model, called Patient Aligned Care Teams (PACTs), to improve access, coordination, and patient-centered care. We evaluated changes in reported implementation of PCMH components in all VA primary care clinics, and patients' utilization of acute and non-acute care and total costs after 2 years. STUDY DESIGN/METHODS:Longitudinal study of 2,607,902 patients from 796 VA primary care clinics. METHODS:Clinics were surveyed for their implementation of PCMH components. Patient outcomes were measured by outpatient visits for primary care, specialty care, telephone care, and emergency department (ED) care; hospitalizations for an ambulatory care-sensitive condition (ACSC); and costs of VA care in fiscal years (FYs) 2009 and 2011. Multi-level, multivariable models predicted changes in utilization and costs, adjusting for patients' health status, clinic PCMH component scores, and a patient fixed effect. RESULTS:Clinics reported large improvements in adoption of all PCMH components from FY 2009 to FY 2011. Higher organization of practice scores was associated with fewer primary care visits (P = .012). Greater care coordination/transitions was modestly associated with more specialty care visits (P = .010) and fewer ED visits (P = .018), but quality/performance improvement was associated with more ED visits (P = .032). None of the PCMH components were significantly related to telephone visits, ACSC hospitalizations, or total healthcare costs. CONCLUSIONS:Improvements under organization of practice and care coordination/transitions appear to have impacted outpatient care, but reductions in acute care were largely absent.
PMID: 25880624
ISSN: 1936-2692
CID: 3115982

Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics

Helfrich, Christian D; Dolan, Emily D; Fihn, Stephan D; Rodriguez, Hector P; Meredith, Lisa S; Rosland, Ann-Marie; Lempa, Michele; Wakefield, Bonnie J; Joos, Sandra; Lawler, Lauren H; Harvey, Henry B; Stark, Richard; Schectman, Gordon; Nelson, Karin M
INTRODUCTION/BACKGROUND:Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams׳ abilities to deliver patient-centered care. MATERIAL AND METHODS/METHODS:We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity. RESULTS:4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (β=32, P<0.0001) and history of change in the clinic (β=18, P=0008) (both team processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (β=0.16-0.34, P=<0.0001), and lower improvements in patient-centered care (β=-0.19, P=0.001). CONCLUSIONS:Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures. IMPLICATIONS/CONCLUSIONS:Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics.
PMID: 26250630
ISSN: 2213-0772
CID: 3115332

Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use

Nelson, Karin M; Helfrich, Christian; Sun, Haili; Hebert, Paul L; Liu, Chuan-Fen; Dolan, Emily; Taylor, Leslie; Wong, Edwin; Maynard, Charles; Hernandez, Susan E; Sanders, William; Randall, Ian; Curtis, Idamay; Schectman, Gordon; Stark, Richard; Fihn, Stephan D
IMPORTANCE/OBJECTIVE:In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation. OBJECTIVES/OBJECTIVE:To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes. DESIGN, SETTING, AND PARTICIPANTS/METHODS:We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care. MAIN OUTCOMES AND MEASURES/METHODS:Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout. RESULTS:Fifty-three items were included in the PACT Implementation Progress Index (Pi2). Compared with the 87 clinics in the lowest decile of the Pi2, the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001). CONCLUSIONS AND RELEVANCE/CONCLUSIONS:The extent of PCMH implementation, as measured by the Pi2, was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes.
PMID: 25055197
ISSN: 2168-6114
CID: 3118072

Challenges facing primary care practices aiming to implement patient-centered medical homes

Farmer, Melissa M; Rose, Danielle E; Rubenstein, Lisa V; Canelo, Ismelda A; Schectman, Gordon; Stark, Richard; Yano, Elizabeth M
BACKGROUND:While the potential of patient-centered medical homes (PCMH) is promising, little is known empirically about the frontline challenges that primary care (PC) leaders face before making the decision to implement PCMH, let alone in making it a reality. OBJECTIVE:Prior to the design and implementation of the Veterans Health Administration's (VA) national PCMH model--Patient Aligned Care Teams (PACT)--we identified the top challenges faced by PC directors and examined the organizational and area level factors that influenced those challenges. DESIGN AND PARTICIPANTS/METHODS:A national cross-sectional key informant organizational survey was fielded to the census of PC directors at VA medical centers and large community-based outpatient clinics (final sample n = 229 sites). MAIN MEASURES/METHODS:PC directors were asked to rate the degree to which they faced 48 management challenges in eight PCMH-related domains (access, preventive care, chronic diseases requiring care in PC, challenging medical conditions, mental health/substance abuse, special populations, PC coordination of care, and clinical informatics). Responses were dichotomized as moderately-to-extremely challenging versus somewhat-slightly-not at all challenging. Items were rank ordered; chi square or regression techniques were used to examine variations in facility size, type, urban/rural location, and region. KEY RESULTS/RESULTS:On average, VA PC directors reported 16 moderate-to-extreme challenges, and the top 20 challenges spanned all eight PCMH domains. Four of the top 20 challenges, including the top two challenges, were from the clinical informatics domain. Management of chronic non-malignant pain requiring opiate therapy was the third most reported challenge nationwide. Significant organizational and area level variations in reported challenges were found especially for care coordination. CONCLUSIONS:Better understanding of PC challenges ahead of PCMH implementation provides important context for strategic planning and redesign efforts. As a national healthcare system, the VA provides a unique opportunity to examine organizational and area determinants relevant to other PCMH models.
PMCID:4070226
PMID: 24715394
ISSN: 1525-1497
CID: 3119012

Elements of team-based care in a patient-centered medical home are associated with lower burnout among VA primary care employees

Helfrich, Christian D; Dolan, Emily D; Simonetti, Joseph; Reid, Robert J; Joos, Sandra; Wakefield, Bonnie J; Schectman, Gordon; Stark, Richard; Fihn, Stephan D; Harvey, Henry B; Nelson, Karin
BACKGROUND:A high proportion of the US primary care workforce reports burnout, which is associated with negative consequences for clinicians and patients. Many protective factors from burnout are characteristics of patient-centered medical home (PCMH) models, though even positive organizational transformation is often stressful. The existing literature on the effects of PCMH on burnout is limited, with most findings based on small-scale demonstration projects with data collected only among physicians, and the results are mixed. OBJECTIVE:To determine if components of PCMH related to team-based care were associated with lower burnout among primary care team members participating in a national medical home transformation, the VA Patient Aligned Care Team (PACT). DESIGN/METHODS:Web-based, cross-sectional survey and administrative data from May 2012. PARTICIPANTS/METHODS:A total of 4,539 VA primary care personnel from 588 VA primary care clinics. MAIN MEASURES/METHODS:The dependent variable was burnout, and the independent variables were measures of team-based care: team functioning, time spent in huddles, team staffing, delegation of clinical responsibilities, working to top of competency, and collective self-efficacy. We also included administrative measures of workload and patient comorbidity. KEY RESULTS/RESULTS:Overall, 39 % of respondents reported burnout. Participatory decision making (OR 0.65, 95 % CI 0.57, 0.74) and having a fully staffed PACT (OR 0.79, 95 % CI 0.68, 0.93) were associated with lower burnout, while being assigned to a PACT (OR 1.46, 95 % CI 1.11, 1.93), spending time on work someone with less training could do (OR 1.29, 95 % CI 1.07, 1.57) and a stressful, fast-moving work environment (OR 4.33, 95 % CI 3.78, 4.96) were associated with higher burnout. Longer tenure and occupation were also correlated with burnout. CONCLUSIONS:Lower burnout may be achieved by medical home models that are appropriately staffed, emphasize participatory decision making, and increase the proportion of time team members spend working to the top of their competency level.
PMCID:4070238
PMID: 24715396
ISSN: 1525-1497
CID: 3119022

Orchestrating large organizational change in primary care: the Veterans' Health Administration experience implementing a patient-centered medical home [Editorial]

Schectman, Gordon; Stark, Richard
PMCID:4070232
PMID: 24715405
ISSN: 1525-1497
CID: 3119032