Determinants of Timely Access to Recanalization Treatments and Outcomes in Pediatric Ischemic Stroke.

BACKGROUND: Timely revascularization in acute arterial ischemic stroke (AIS) is paramount for optimal outcomes. However, factors causing treatment delays in pediatric AIS remain understudied. We investigated determinants affecting the time from symptom onset or last-known-well to the start of recanalization treatment in pediatric AIS. METHODS: We conducted an ancillary analysis of the French KID-CLOT study (The National Retrospective Study of Recanalization Treatments in Pediatric Arterial Ischemic Stroke), considering patients with pediatric AIS receiving recanalization treatments (IV thrombolysis IVT and mechanical thrombectomy) from 2015 to 2018. The study assessed prehospital triage's impact, direct versus transferred admissions, and unit type (pediatric versus adult) on treatment delay and clinical outcomes using modified Rankin Scale at 1 year. RESULTS: Among 68 patients (median age, 11 [IQR, 4-16]; initial PedNIHSS, 13 [IQR, 7-19]), treatment modalities were IVT (n=31), and mechanical thrombectomy (n=23), and IVT+mechanical thrombectomy (n=14). Prehospital triage significantly reduced last-known-well to treatment delay (overall, 229 versus 270 minutes; P=0.01), most notably for and mechanical thrombectomy (P<0.001). There was no substantial delay difference between direct and transferred admissions, or between unit types, although a trend favored adult units (370.3 versus 436.73 minutes; P=0.06). Prehospital triage correlated with improved outcomes, with a shift to lower modified Rankin Scale scores (P=0.021). CONCLUSIONS: For pediatric AIS treated with reperfusion therapy, prehospital triage emerges as a pivotal factor in reducing treatment delays and enhancing outcomes. These findings underscore the need for a dedicated prehospital stroke protocol for children. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03887143.

When Anticoagulation Backfires - Heparin-Induced Thrombocytopenia and Acute Stent Thrombosis following Endovascular Therapy for Deep Vein Thrombosis: A Case Report.

We report a rare case of heparin-induced thrombocytopenia with thrombosis (HITT) following treatment for May-Thurner syndrome complicated by deep vein thrombosis (DVT), which resulted in venous stent thrombosis. A 27-year-old male with acute left lower-limb DVT successfully underwent thrombolysis and stenting for May-Thurner syndrome. However, the patient developed recurrent thrombosis and thrombocytopenia 3 days post-procedure. HITT was confirmed by a positive antiplatelet factor 4-heparin antibody test. After discontinuing heparin, the patient was successfully treated with fondaparinux, followed by repeat thrombectomy and thrombolysis, and then transitioned to warfarin. This is the second reported case of venous stent thrombosis due to HITT in May-Thurner syndrome. This case underscores the importance of early recognition and prompt management of HITT using alternative anticoagulants like fondaparinux to prevent complications such as venous limb gangrene. Further randomized controlled trials are required to evaluate the safety and efficacy of fondaparinux in HITT.

Stroke: Evolution of newer treatment modalities for acute ischemic stroke.

Acute ischemic stroke is one of the leading causes of morbidity and mortality worldwide. Restoration of cerebral blood flow to affected ischemic areas has been the cornerstone of therapy for patients for eligible patients as early diagnosis and treatment have shown improved outcomes. However, there has been a paradigm shift in the management approach over the last decade, and with the emphasis currently directed toward including newer modalities such as neuroprotection, stem cell treatment, magnetic stimulation, anti-apoptotic drugs, delayed recanalization, and utilization of artificial intelligence for early diagnosis and suggesting algorithm-based management protocols.

Successful nonsurgical therapeutic management in a case of early mechanical aortic prosthetic thrombosis and coronary embolism after a modified Bentall procedure.

Prosthetic valve thrombosis, although rare, is a life-threatening complication of valve replacement surgery. The authors present an atypical case of a modified Bentall procedure with the CarboSeal Valsalva™ conduit complicated by an early mechanical prosthetic aortic valve thrombosis and coronary embolism. The patient was successfully treated with an emergency percutaneous coronary angioplasty and intracoronary thrombus aspiration of the left anterior descending artery, followed by a systemic 10 mg bolus of tissue plasminogen activator followed by ultraslow (25 h) infusion of low-dose (25 mg), while supported with venoarterial extracorporeal membrane oxygenation.

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Successful treatment of acute device thrombosis of patent foramen ovale with slow infusion of low-dose thrombolytic therapy.

Background: Percutaneous closure of patent foramen ovale (PFO) is used in selected individuals to eliminate the risk of recurrent cerebral embolism due to paradoxical embolization. Although device thrombosis is rare, it can cause serious complications. Herein, we report a 40-year-old woman who developed acute PFO closure device-associated thrombus and was subsequently treated with slow infusion of low-dose tissue plasminogen activator (t-PA) (25 mg/6 h). Case summary: A 40-year-old woman was admitted to the hospital because of an cerebrovascular accident (CVA). Computed tomography and magnetic resonance imaging of the brain demonstrated the presence of an ischaemic lesion in the right cerebellar infarct. Since no pathological finding was detected that could cause CVA, it was considered that there might be paradoxical embolism due to PFO. Percutaneous PFO closure was decided by the heart and brain team. The occluder was implanted under transoesophageal echocardiography (TEE) and fluoroscopy guidance. Although activated clotting time was 250 s, hypermobile acute thrombus measuring 11 × 5 mm was seen on the left atrial side of the PFO device. Slow infusion of low-dose t-PA treatment was given. As soon as after a single-dose t-PA, control TEE was performed and it was seen that almost the entire thrombus was lysed. The patient did not have any complications during the treatment period. Discussion: Acute PFO device thrombosis is a rare but important complication. If there is no contraindication for lytic treatment in acutely developing large PFO device thrombosis, slow infusion of low-dose t-PA may be useful.

Pharmacokinetics and pharmacodynamics of low doses of recombinant tissue plasminogen activator to establish a model for biosimilarity comparisons.

Background: Recombinant tissue plasminogen activator (rt-PA) is a thrombolytic agent and essential in emergency medical care. Given recent supply shortages, the availability of biosimilar products is an urgent medical need. However, biosimilarity trials are difficult to perform in critically ill patients. Objectives: The aim of this pilot study was to investigate the pharmacokinetics and pharmacodynamics of low rt-PA doses to establish a model for testing proposed biosimilars in healthy volunteers. Methods: Eight healthy volunteers received 0.02 to 0.05 mg/kg rt-PA on 3 study days; blood samples were obtained every 4 minutes after the end of the bolus infusion to measure rt-PA antigen levels by enzyme immunoassay, and the pharmacodynamics were assessed with rotational thromboelastometry. Results: Bolus infusion of low rt-PA doses was safe and well tolerated. Maximal plasma concentrations and the area under the curve increased dose-dependently. Time-concentration curves were clearly separated between the lower and the higher doses. As expected, the half-live of rt-PA was short (4.5-5 min), and representative for therapeutic doses. The intrasubject coefficient variations were moderate (<25%). Bolus infusion of rt-PA dose-dependently shortened lysis time and lysis onset time in both dose groups and caused maximum clot lysis of 100% in all participants. Conclusion: In conclusion, the pharmacokinetics of rt-PA was dose linear and displayed limited intrasubject variability even at subtherapeutic doses. The half-life and thus clearance of rt-PA was representative of full therapeutic doses. The lysis time was shortened in a dose and time-dependent fashion and was clearly distinguishable between doses. Thus, the model appears to be suitable and sensitive to test biosimilarity.

The Delayed Diagnosis of a Submassive Pulmonary Embolism Following Influenza A Infection Treated With Half-Dose Tenecteplase: A Case Report.

The coronavirus 2019 (COVID-19) pandemic has brought renewed attention to thrombotic complications arising from respiratory viral infections, driven by inflammatory responses and activation of the coagulation cascade. While influenza typically resolves on its own, information about its thromboembolic risks remains limited. The persistence of symptoms and the similarity between influenza symptoms and those of pulmonary embolism (PE) often lead to diagnostic delays, which can significantly impact patient outcomes. We discuss a case of a 62-year-old woman with a history of hypertension and hyperlipidemia who presented with dyspnea, syncope, and persistent symptoms following influenza A infection. Despite initial treatment with Tamiflu and subsequent antibiotics for presumed pneumonia, her condition worsened, leading to syncope and admission to the hospital. A diagnostic workup revealed saddle pulmonary emboli with right ventricular strain. She was treated with a half-dose of tenecteplase, resulting in significant clinical improvement and a notable reduction in thrombus burden on follow-up imaging. The thromboembolic complications of influenza A are not extensively documented compared to COVID-19, yet they can present with severe outcomes. Submassive PE, characterized by hemodynamic stability with signs of right ventricular strain, poses treatment challenges. While full-dose thrombolytics are generally avoided in intermediate-risk PE due to bleeding risks, half-dose thrombolytics such as tenecteplase can offer a safer alternative. Though not FDA-approved specifically for PE, tenecteplase has shown efficacy and was effectively used in this case. Half-dose thrombolytics, including tenecteplase, may be a viable treatment option for certain cases of PE, offering a balance between efficacy and safety. This case highlights the importance of considering PE in patients with persistent respiratory symptoms post-influenza and demonstrates the potential of tenecteplase in managing submassive PE.

David G. Sherman Lecture: Improving Stroke Diagnosis and Treatment-A Journey Toward the End of Time.

In the 2024 David G. Sherman Lecture, Steven J. Warach, illustrating with examples from his research, walks through the history of magnetic resonance imaging in acute stroke from the 1990s and early 2000s with the introduction, validation, and application of diffusion-weighted imaging, penumbral imaging (the diffusion-perfusion mismatch), and other imaging markers of the acute stroke pathology into routine clinical practice and stroke trials. The adaptation of diffusion-weighted imaging for clinical scanners in the acute hospital setting began a revolution in ischemic stroke diagnosis as the presence, location, and size of ischemic lesions could now be visualized at the earliest times after stroke onset when computed tomography and conventional magnetic resonance imaging still appeared normal. In combination with perfusion magnetic resonance imaging, diffusion-weighted imaging made imaging of the ischemic penumbra a practical reality for routine clinical use and feasible for integration as a selection tool into clinical trials. It was apparent from the initial use of diffusion-perfusion imaging in acute stroke that many patients had persistence of penumbra as late as 24 hours after stroke onset although the probability of penumbra decreased over time. The therapeutic time window for ischemic stroke selected by clinical and temporal criteria reflected the decreased proportion of patients with the therapeutic target over time rather than the absence of the penumbral target in all patients at later times. This work provided the empirical and conceptual framework for the shift toward selection and evaluation of patients for acute stroke therapies based on direct observation of the target pathology and away from the exclusive dependence on clinical and temporal surrogates to infer the presence of stroke therapeutic targets, a shift that has expanded the indications for acute reperfusion therapies over the last 10 years.

Letter to the editor: Epidemiological profile of stroke in Qatar: Insights from a seven-year observational study.

We have thoroughly engaged with the article titled "Epidemiological profile of stroke in Qatar: Insights from a seven-year observational study". The author's diligent efforts regarding this critical subject matter are greatly appreciated [1], which is worthy of reader acknowledgment. We sincerely appreciate the author's ongoing efforts on this vital subject, which deserve recognition. The primary conclusion of the article is that the incidence of stroke is increasing. However, it remains relatively low compared to the rising trend observed in Western countries. We agree with this assessment. It highlights the multi-ethnic population and unique risk factors of the Qatari and expatriate populations that are associated with stroke. The necessity of investing in designated stroke care strategies and balanced care for all population groups is underscored by the improved emergency medical services and healthcare access that have contributed to improving stroke care. Based on this, there are a few additional elements that could have contributed to the article's conclusion.

Increased peripheral leukocyte aggravates brain injury and leads to poor outcome in stroke patients receiving intravenous thrombolysis: A study based on clinical evidence.

Whether the dynamic development of peripheral inflammation aggravates brain injury and leads to poor outcome in stroke patients receiving intravenous thrombolysis (IVT), remains unclear and warrants further study. In this study, total of 1034 patients with acute ischemic stroke who underwent IVT were enrolled. Serum leukocyte variation (whether increase from baseline to 24 h after IVT), National Institutes of Health Stroke Scale (NIHSS), infarct volume, early neurologic deterioration (END), the unfavorable outcome at 3-month (modified Rankin Scale [mRS] score ≥3) and mortality were recorded. Serum brain injury biomarkers, including Glial fibrillary acidic protein (GFAP), ubiquitin c-terminal hydrolase L1 (UCH-L1), S100ß, neuron-specific enolase (NSE), were measured to reflect the extent of brain injury. We found that patients with increased serum leukocytes had elevated brain injury biomarkers (GFAP, UCH-L1, and S100ß), larger infarct volume, higher 24 h NIHSS, higher proportion of END, unfavorable outcome and mortality. Furthermore, an increase in serum leukocytes was independently associated with infarct volume, 24 h NIHSS, END, and unfavorable outcome at 3 months, and serum UCH-L1, S100ß, and NSE levels. These results suggest that an increase in serum leukocytes indicates severe brain injury and may be used to predict the outcome of patients with ischemic stroke who undergo IVT.

Decoding Pulmonary Embolism: Pathophysiology, Diagnosis, and Treatment.

Pulmonary Embolism (PE) is a life-threatening condition initiated by the presence of blood clots in the pulmonary arteries, leading to severe morbidity and mortality. Underlying mechanisms involve endothelial dysfunction, including impaired blood flow regulation, a pro-thrombotic state, inflammation, heightened oxidative stress, and altered vascular remodeling. These mechanisms contribute to vascular diseases stemming from PE, such as recurrent thromboembolism, chronic thromboembolic pulmonary hypertension, post-thrombotic syndrome, right heart failure, and cardiogenic shock. Detailing key risk factors and utilizing hemodynamic stability-based categorization, the review aims for precise risk stratification by applying established diagnostic tools and scoring systems. This article explores both conventional and emerging biomarkers as potential diagnostic tools. Additionally, by synthesizing existing knowledge, it provides a comprehensive outlook of the current enhanced PE management and preventive strategies. The conclusion underscores the need for future research to improve diagnostic accuracy and therapeutic effectiveness in PE.

Targeting Fibrinolytic Inhibition for Venous Thromboembolism Treatment: Overview of an Emerging Therapeutic Approach.

Venous thrombosis and pulmonary embolism (venous thromboembolism) are important causes of morbidity and mortality worldwide. In patients with venous thromboembolism, thrombi obstruct blood vessels and resist physiological dissolution (fibrinolysis), which can be life threatening and cause chronic complications. Plasminogen activator therapy, which was developed >50 years ago, is effective in dissolving thrombi but has unacceptable bleeding risks. Safe dissolution of thrombi in patients with venous thromboembolism has been elusive despite multiple innovations in plasminogen activator design and catheter-based therapy. Evidence now suggests that fibrinolysis is rigidly controlled by endogenous fibrinolysis inhibitors, including α2-antiplasmin, plasminogen activator inhibitor-1, and thrombin-activable fibrinolysis inhibitor. Elevated levels of these fibrinolysis inhibitors are associated with an increased risk of venous thromboembolism in humans. New therapeutic paradigms suggest that accelerated and effective fibrinolysis may be achieved safely by therapeutically targeting these fibrinolytic inhibitors in venous thromboembolism. In this article, we discuss the role of fibrinolytic components in venous thromboembolism and the current status of research and development targeting fibrinolysis inhibitors.

Rural Hospital Performance in Guideline-Recommended Ischemic Stroke Thrombolysis, Secondary Prevention, and Outcomes.

BACKGROUND: Existing data suggested a rural-urban disparity in thrombolytic utilization for ischemic stroke. Here, we examined the use of guideline-recommended stroke care and outcomes in rural hospitals to identify targets for improvement. METHODS: This retrospective cohort study included patients (aged ≥18 years) treated for acute ischemic stroke at Get With The Guidelines-Stroke hospitals from 2017 to 2019. Multivariable mixed-effect logistic regression was used to compare thrombolysis rates, speed of treatment, secondary stroke prevention metrics, and outcomes after adjusting for patient- and hospital-level characteristics and stroke severity. RESULTS: Among the 1 127 607 patients admitted to Get With The Guidelines-Stroke hospitals in 2017 to 2019, 692 839 patients met the inclusion criteria. Patients who presented within 4.5 hours were less likely to receive thrombolysis in rural stroke centers compared with urban stroke centers (31.7% versus 43.5%; adjusted odds ratio [aOR], 0.72 [95% CI, 0.68-0.76]) but exceeded rural nonstroke centers (22.1%; aOR, 1.26 [95% CI, 1.15-1.37]). Rural stroke centers were less likely than urban stroke centers to achieve door-to-needle times of ≤45 minutes (33% versus 44.7%; aOR, 0.86 [95% CI, 0.76-0.96]) but more likely than rural nonstroke centers (aOR, 1.24 [95% CI, 1.04-1.49]). For secondary stroke prevention metrics, rural stroke centers were comparable to urban stroke centers but exceeded rural nonstroke centers (aOR of 1.66, 1.94, 2.44, 1.5, and 1.72, for antithrombotics within 48 hours of admission, antithrombotics at discharge, anticoagulation for atrial fibrillation/flutter, statin treatment, and smoking cessation, respectively). In-hospital mortality was similar between rural and urban stroke centers (aOR, 1.11 [95% CI, 0.99-1.24]) or nonstroke centers (aOR, 1.00 [95% CI, 0.84-1.18]). CONCLUSIONS: Rural hospitals had lower thrombolysis utilization and slower treatment times than urban hospitals. Rural stroke centers provided comparable secondary stroke prevention treatment to urban stroke centers and exceeded rural nonstroke centers. These results reveal important opportunities and specific targets for rural health equity interventions.

Epidemiology, Pathophysiology, and Current Treatment Strategies in Stroke.

Both ischemic and hemorrhagic strokes are critical health issues and the incidence is on the rise. The rapid neurological degeneration that can occur with either type of stroke warrants prompt medical attention. In the article, we critically reviewed the literature examining their incidence, pathophysiology, and present treatment strategies. Clinical trials show conflicting findings, with ischemic strokes accounting for 87% of all strokes. Brain injury following an ischemic stroke results in cell death and necrosis, immune cells being the primary actors in the process of neuroinflammation. In order to develop neuroprotective drugs against ischemic stroke, detailed investigation of glutamate production and metabolism as well as downstream pathways controlled by glutamate receptors provides significant information on the underlying mechanisms. The permeability of the blood-brain barrier and the degradation of glutamine synthase are two potential mechanisms by which peritoneal dialysis accelerates brain-to-blood glutamate clearance and thus reduces glutamate levels in the brain after a stroke. Oxidative stress in an ischemic stroke disturbs the oxidant-antioxidant balance, which is particularly problematic for brain cells that are high in polyunsaturated fatty acids. Because of demographic factors like age, sex, race/ethnicity, and socioeconomic status, the incidence and prevalence of stroke differ across people and regions. For rapid diagnosis and treatment decisions, diagnostic imaging tools such as vascular imaging, CT, and MRI are essential. To aid in the recovery and lessen neurological impairments following a stroke, novel avenues of research are under investigation on neuroprotective medications that target inflammation, oxidative stress, and neuronal death.

Association between PAI-1 4G/5G genotype and residual thrombus in acute mesenteric venous thrombosis.

OBJECTIVE: Plasminogen activator inhibitor-1 (PAI-1) is the most important inhibitor of plasminogen activator. The functional 4G/5G polymorphism of the gene coding for PAI-1 may affect PAI-1 plasmatic activity, influencing the imbalance between coagulation and fibrinolysis cascades. In this study, we investigated the association between the PAI-1 4G/5G genotype and the development and residual thrombus of acute primary mesenteric venous thrombosis (MVT). METHODS: The clinical data of 34 patients who underwent acute primary MVT were retrospectively reviewed. Fluorescence in situ hybridization was used to determine if patients had the 4G/5G polymorphism in the promoter of the PAI-1 gene. Patients were stratified according to the genotype of PAI-1. RESULTS: 11 patients (32.3%) were homozygous for the 4G genotype, 23 patients (67.6%) were non-homozygous for the 4G genotype (5G/5G). The extent of thrombosis was not correlated with the PAI-4G/5G polymorphism. After a mean follow-up of 16.6 ± 10.4 months, the 4G/4G genotype had a significantly larger thrombus burden (p < 0.05). 54% of patients in the 4G/4G genotype group had no lessening in the degree of mesenteric venous thrombosis, significantly higher than other patients (4G/5G + 5G/5G genotypes) (p < 0.05). CONCLUSION: The PAI-1 4G/4G predicts residual thrombus of mesenteric veins after the acute phase.

Standardized Data Elements for Patients With Acute Pulmonary Embolism: A Consensus Report From the Pulmonary Embolism Research Collaborative.

Recent advances in therapy and the promulgation of multidisciplinary pulmonary embolism teams show great promise to improve management and outcomes of acute pulmonary embolism (PE). However, the absence of randomized evidence and lack of consensus leads to tremendous variations in treatment and compromises the wide implementation of new innovations. Moreover, the changing landscape of health care, where quality, cost, and accountability are increasingly relevant, dictates that a broad spectrum of outcomes of care must be routinely monitored to fully capture the impact of modern PE treatment. We set out to standardize data collection in patients with PE undergoing evaluation and treatment, and thus establish the foundation for an expanding evidence base that will address gaps in evidence and inform future care for acute PE. To do so, >100 international PE thought leaders convened in Washington, DC, in April 2022 to form the Pulmonary Embolism Research Collaborative. Participants included physician experts, key members of the US Food and Drug Administration, patient representatives, and industry leaders. Recognizing the multidisciplinary nature of PE care, the Pulmonary Embolism Research Collaborative was created with representative experts from stakeholder medical subspecialties, including cardiology, pulmonology, vascular medicine, critical care, hematology, cardiac surgery, emergency medicine, hospital medicine, and pharmacology. A list of critical evidence gaps was composed with a matching comprehensive set of standardized data elements; these data points will provide a foundation for productive research, knowledge enhancement, and advancement of clinical care within the field of acute PE, and contribute to answering urgent unmet needs in PE management. Evidence produced through the Pulmonary Embolism Research Collaborative, as it is applied to data collection, promises to provide crucial knowledge that will ultimately produce a robust evidence base that will lead to standardization and harmonization of PE management and improved outcomes.

Effect of stroke etiology on treatment-related outcomes in young adults with large vessel occlusion: Results from a retrospective cohort study.

INTRODUCTION: Large vessel occlusion-acute ischemic stroke (LVO-AIS) is infrequent in young adults and exhibits distinct stroke mechanisms compared to older adults. This study sought to evaluate the impact of varying stroke etiologies on treatment-related outcomes in young adults with LVO-AIS, an aspect that remains unclear. METHODS: This retrospective cohort study included patients aged 18-50 presenting with AIS from January 2017 to December 2021 within our multi-center stroke network. Patients with LVO on CTA/MRA at presentation were included. We assessed demographics, stroke etiology (TOAST classification), and treatment-related outcomes. Based on intervention received, patients were divided into 5 groups [IV-thrombolysis (IVT) only, Mechanical Thrombectomy (MT) only, IVT+MT, no treatment, unsuccessful MT]. RESULTS: Among 1210 AIS patients, 220 with LVO were included. The median age was 42 (36, 46). 75 (34.1 %) patients underwent successful MT (46.7 % received IVT+MT). 26 (11.8 %) received IVT only, 110 (50 %) received neither intervention, and 9 (4.1 %) underwent unsuccessful MT. Per TOAST, 17.4 % had large artery atherosclerosis (LAA), 19.2 % cardio-embolism, 28.6 % stroke of other etiology, and 34.7 % had undetermined etiology. Favorable thrombectomy outcomes (TICI 2b/2c/3) were observed in 87.2 %. Discharge NIH Stroke Scale (NIHSS) scores improved for patients with IVT+MT in all TOAST categories except LAA. CONCLUSIONS: Young adults with LVO-AIS had good outcomes irrespective of stroke etiology, except LAA, which was associated with a higher discharge NIHSS. Moreover, 50 % of young adults in our study received no intervention, a quarter of those owing to delayed presentation. Further studies are needed to identify barriers in seeking acute treatment in young adults with LVO-AIS.

Analysis of Deep Vein Thrombosis: A Prospective Observational Study.

Objective This prospective observational study aimed to investigate the prevalence, acquired risk factors, and treatment outcomes of deep vein thrombosis (DVT) at a tertiary care center in India. Materials and methods Conducted from 2022 to 2024, the study included 100 patients diagnosed with lower extremity DVT. The study subjects included patients visiting the general surgery, vascular surgery, surgical gastroenterology, general medicine, emergency medicine, and obstetrics and gynecology departments with symptoms suggestive of DVT. The primary objectives were to evaluate the effectiveness of conventional anticoagulation and thrombolytic therapy as well as to assess the various acquired risk factors for DVT. Patients underwent comprehensive clinical and biochemical evaluations, including venous Doppler ultrasound, and were treated based on their clinical presentations. The study's primary end outcome was early recanalization rates on day 14 post-initiation of treatment and occurrence of post-thrombotic syndrome (PTS). Secondary outcome measures included duration of hospital stay, time taken to return to work and early complications. Results The highest incidence of DVT was in individuals in their forties, with a mean age of 44.84+/-11.71 years and a female preponderance of 58% (n=58). Key acquired risk factors identified included hypertension (25%; n=25), diabetes mellitus (20%; n=20), obesity (16%; n=16), and smoking (34%; n=34). Obesity (16%; n=16), a history of DVT (25%; n=25), trauma/immobilization (9%; n=9), pregnancy (10%; n=10), smoking (34%; n=34), and cancer (20%; n=20) were also identified as important acquired risk factors contributing to the occurrence of DVT. Amongst the study participants, 28% (n=28) had femoro-popliteal segment involvement, 36% (n=36) had calf vein thrombosis, and the remaining 36% (n=36) showed femoro-iliac segment thrombosis. Conventional anticoagulation was administered to 69% (n=69) of patients, while 31% (n=31) received thrombolytic therapy. Both treatments showed similar recanalization rates, but thrombolytic therapy was associated with a longer hospital stay (8.61+/-1.65 days; p=0.024; p<0.05) and return to work period (14.65+/-2.31 days; p=0.012; p<0.05). Post-thrombotic syndrome was less common in the thrombolytic therapy group (3%; n=3). Three patients died in the study, with the cause being pulmonary embolism. The descriptive statistics were computed to delineate the study sample. After completion of data collection, data analysis was achieved using SPSS for Windows, Version 16 (Released 2007; SPSS Inc., Chicago, United States), and the correlations sought after were achieved using the chi-square test of significance. Conclusion The study underscores the importance of recognizing and managing acquired risk factors for DVT, thereby facilitating early diagnosis and ultimately reducing morbidity and mortality. Understanding these factors and employing effective treatment strategies are crucial for better management and prevention of DVT, enhancing patient outcomes.

Heterogeneity in measurement of NIHSS: a systematic review and meta-analysis.

BACKGROUND: The National Institutes of Health Stroke Scale (NIHSS) is a pivotal clinical tool used to assess patients with acute stroke. However, substantial heterogeneity in the application and interpretation of stroke scale items can occur. This systematic review aimed to elucidate heterogeneity in measuring the NIHSS. MATERIAL AND METHODS: A literature search was performed on PubMed/OVID/Cochran's CENTRAL from inception to 2023. The references of the included papers were reviewed for further eligible articles. Clinical characteristic, NIHSS values, and sources of heterogeneity were recorded. Non-human and non-English language articles were excluded. The study quality was assessed using MINORS and GRADE. Meta-analysis and meta-regression were performed using a random-effects model to explore the sources of heterogeneity. RESULTS: Twenty-one papers for a total of 818 patients (mean per study: 39 ± 37) and 9696 NIHSS examinations (median per study: 8 [CI95% 2 to 42]) were included. Motor function had a higher ICC agreement (ranging from 0.85 ["Right Leg"] to 0.90 ["Right Arm"]) compared to the remaining items (ranging from 0.58 ["Facial Palsy"] to 0.85 ["Level of consciousness commands"]. The meta-regression showed a low effect size of covariates such as language version, remote evaluation, and retrospective analysis on NIHSS items (e.g., for "Level of consciousness commands," language effect was 0.30 [CI95% 0.20 to 0.48] and for "Visual", the retrospective assessment effect was -0.27 [CI95% -0.51 to -0.03]). CONCLUSION: The NIHSS scores showed moderate to excellent inter-rater agreement, with the highest heterogeneity in non-motor function evaluation. Using a non-English version, remote evaluation and retrospective analysis had small effects in terms of heterogeneity in the NIHSS scores.