Background and Purpose-Infarct in a new previously unaffected territory (INT) is a potential complication of endovascular treatment. We applied a recently proposed methodology to identify and classify INTs in the ESCAPE randomized controlled trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times). Methods-The core laboratory identified INTs on 24-hour follow-up imaging, blinded to treatment allocation, after assessing all baseline imaging. INTs were classified into 3 types (I-III) and 2 subtypes (A/B) based on size and if catheter manipulation was likely performed across the vessel territory ostium. Logistic regression was used to understand the effect of multiple a priori identified variables on INT occurrence. Ordinal logistic regression was used to analyze the effect of INTs on modified Rankin Scale shift at 90 days. Results-From 308 patients included, 14 INTs (4.5% overall; 2.8% on follow-up noncontrast computed tomography, 11.7% on follow-up magnetic resonance imaging) were identified (5.0% in endovascular treatment arm versus 4.0% in control arm [P=0.7]). The use of intravenous alteplase was associated with a 68% reduction in the odds of INT occurrence (3.0% with versus 9.1% without; odds ratio, 0.32; 95% confidence interval, 0.11-0.96; adjusted for age, sex, and treatment type). No other variables were associated with INTs. INT occurrence was associated with reduced probability of good clinical outcome (common odds ratio, 0.25; 95% confidence interval, 0.09-0.74; adjusted for age, type of treatment, and follow-up scan). Conclusions-INTs are uncommon, detected more frequently on follow-up magnetic resonance imaging, and affect clinical outcome. In experienced centers, endovascular treatment is likely not causal, whereas intravenous alteplase may be therapeutic.
Background and Purpose-The goal of reperfusion therapy in acute ischemic stroke is to limit brain infarction. The objective of this study was to investigate whether the beneficial effect of endovascular treatment on functional outcome could be explained by a reduction in post-treatment infarct volume. Methods-The Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis onMinimizing CT to Recanalization Times (ESCAPE) trial was a multicenter randomized open-label trial with blinded outcome evaluation. Among 315 enrolled subjects (endovascular treatment n=165; control n=150), 314 subject's infarct volumes at 24 to 48 hours on magnetic resonance imaging (n=254) or computed tomography (n=60) were measured. Posttreatment infarct volumes were compared by treatment assignment and recanalization/reperfusion status. Appropriate statistical models were used to assess relationship between baseline clinical and imaging variables, post-treatment infarct volume, and functional status at 90 days (modified Rankin Scale). Results-Median post-treatment infarct volume in all subjects was 21 mL (interquartile range =65 mL), in the intervention arm, 15.5 mL (interquartile range =41.5 mL), and in the control arm, 33.5 mL (interquartile range =84 mL; P<0.01). Baseline National Institute of Health Stroke Scale (P<0.01), site of occlusion (P<0.01), baseline noncontrast computed tomographic scan Alberta Stroke Program Early CT score (ASPECTS) (P<0.01), and recanalization (P<0.01) were independently associated with post-treatment infarct volume, whereas age, sex, treatment type, intravenous alteplase, and time from onset to randomization were not (P>0.05). Post-treatment infarct volume (P<0.01) and delta National Institute of Health Stroke Scale (P<0.01) were independently associated with 90-day modified Rankin Scale, whereas laterality (left versus right) was not. E verything that we think, plan, or do comes from within the human brain. Our language, our arts and culture, the meaning of being human are all products of the human brain. The drugs, devices, and techniques we have developed for acute ischemic stroke therapy are aimed at saving the human brain from death. Clinical trials in ischemic stroke test if these therapies are capable of reducing damage to the brain. Conclusions-TheseAn ability to speak, listen, and understand; to move, walk, or run; to see and interact with the world around us are all examples of brain functions. Clinical trials use ordinal scales like the modified Rankin Scale (mRS), the National Institute of Health Stroke Scale (NIHSS), or the Barthel index to quantify these functions.1-3 Understandably, none of these scales ever capture the entirety of functions and capabilities of the human brain. Therefore, it is important for stroke therapies being tested within clinical trials to also be able to show that they save brain tissue.Using a detailed post hoc analysis of the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minim...
Introduction: Myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease is a recently described central nervous system (CNS) inflammatory disorder with phenotypic overlap with Neuromyelitis Optica Spectrum Disorder (NMOSD). NMOSD seronegative patients, and those with limited forms of the disorder, become suspects for MOG antibody-associated disease. We describe a multi-ethnic population with MOG antibody seropositivity from the University of British Columbia MS/NMO clinic.Methods: AQP4-antibody seronegative patients presenting 2005–2016 with CNS inflammatory disease suspicious for NMOSD, as well as 20 MS controls, were retrospectively tested for MOG-IgG1 antibodies by live cell-based assay at Oxford Autoimmune Neurology Diagnostic Laboratory (UK) and by a commercial fixed cell-based assay at MitogenDx (Calgary, Canada). Additional MOG seropositive cases were identified through routine clinical interaction (2016–2018) using one of these laboratories. Clinical data was reviewed retrospectively.Results: Retrospective testing identified 21 MOG seropositives (14 by live assay only, 3 by fixed assay only and 4 by both) representing 14% of the “NMOSD suspects” cohort. One multiple sclerosis (MS) control serum was MOG seropositive. Twenty additional MOG positive cases were identified prospectively. Of 42 patients (27 female), median disease onset age was 29 years (range 3–62; 9 pediatric cases), 20 (47%) were non-Caucasian, and 3 (7%) had comorbid autoimmune disease. Most common onset phenotypes were optic neuritis (23, 55%; 8 bilateral) and myelitis (9, 21%; 6 longitudinally extensive) Three of the patients in our cohort experienced cortical encephalitis; two presented with seizures. Onset was moderate-severe in 64%, but 74% had good response to initial steroid therapy. Cumulative relapse probability for the MOG positive group at 1 year was 0.428 and at 4 years was 0.628. Most had abnormal brain imaging, including cortical encephalitis and poorly demarcated subcortical and infratentorial lesions. Few “classic MS” lesions were seen. Optic nerve lesions (frequently bilateral) were long and predominantly anterior, but 5 extended to the chiasm. Spinal cord lesions were long and short, with involvement of multiple spinal regions simultaneously, including the conus medullaris.Conclusions: Our MOG seropositive patients display phenotypes similar to previous descriptions, including cortical lesions with seizures and conus medullaris involvement. Many patients relapsed, predominantly in a different CNS location from onset. Serologic data from two different cell-based antibody assays highlight the discrepancies between live and fixed testing for MOG antibodies.
Background Matted nodes in human papillomavirus (HPV)‐mediated oropharyngeal squamous cell carcinoma (OPC) is an independent predictor of distant metastases and decreased overall survival. We aimed to classify imaging patterns of metastatic lymphadenopathy, analyze our classification system for reproducibility, and assess its prognostic value. Methods The metastatic lymphadenopathy was classified based on radiological characteristics for 216 patients with HPV‐mediated OPC. Patient outcomes were compared and inter‐rater reliability was calculated. Results The presence of ≥3 abutting lymph nodes with imaging features of surrounding extranodal extension (ENE), one subtype of matted nodes, was associated with worse 5‐year overall survival, overall recurrence‐free survival, regional recurrence‐free survival, and distant recurrence‐free survival (p ≤ 0.03). Other patterns were not significantly associated with outcome measures. Overall inter‐rater agreement was substantial (κ = 0.73). Conclusion One subtype of matted nodes defined by ≥3 abutting lymph nodes with imaging features of surrounding ENE is the radiological marker of worst prognosis.
Materials/Methods: We identified cases of treatment-naïve p16(-) LA-HNSCC (stage III-IVB) of the oropharynx (31%), larynx (55%), and hypopharynx (13%) who received definitive (70 Gy) CTX-bioRT (n Z 35), CB-CRT (n Z 43), or CP-CRT (n Z 67) at our institution from 2009 to 2015. Variables with P < .05 on log-rank/Kaplan-Meier analysis were included as covariates in Cox proportional hazards modeling to adjust for potential confounders; variables included: concurrent systemic agent, sex, age, smoking history, T stage, N stage, performance status, and primary tumor site. Results: We identified 145 cases: 107 men (73.7%), median age 60 years (range, 41-87), T3 (63.4%), and N2b (56.6%). There were no statistical differences in sex, age, smoking history, T stage, N stage, performance status, or frequency of primary site among the groups. The most common reasons for CP ineligibility were hearing loss (41.0%), medical comorbidities (35.9%), and renal disease (9%). Median follow up was 3 years. Locoregional control (LRC), distant metastasis-free survival (DMFS), recurrence-free survival (RFS), and overall survival (OS) at 3 years were not statistically different between those treated with CB or CP-CRT. When compared to CTX-bioRT, CB-CRT improved 3-year LRC (81.5 vs 40.0%; P Z .001), RFS (76.9 vs 38.3%; P Z .009), and OS (60.0 vs 55.2%; P Z .05), with a trend toward improved distant metastasis free survival (89.5% vs 65.8%; P Z .06). On MVA CB-CRT remained associated with improved LRC (HR 0.25, 95% CI 0.10-0.67; P Z .006), RFS (HR 0.30, 95% CI 0.12-0.76; P Z 0.01), and OS (HR 0.44, 95% CI 0.20-0.96; P Z .04) compared to CTX-bioRT. On subset analysis of non-oropharynx primary tumors, concurrent platinum agents (CP or CB) were associated with improved 3-year larynx preservation compared to CTX-bioRT (83.6 vs 47.1%; P Z .02). Conclusion: When patients cannot receive CP, CB-CRT is an effective alternative in p16(-) LA-HNSCC. Furthermore, CB-CRT markedly improved LRC, RFS, and OS compared to CTX-bioRT and should be a preferred substitute for CP in this population. Prospective validation of these results is needed.
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