Outcomes after reperfusion therapies in patients with ACA stroke: A multicenter cohort study from the EVATRISP collaboration.

BACKGROUND: Patients with stroke secondary to occlusions of the anterior cerebral artery (ACA) often have poor outcomes. The optimal acute therapeutic intervention for these patients remains unknown. METHODS: Patients with isolated ACA-stroke were identified from 10 centers participating in the EndoVascular treatment And ThRombolysis in Ischemic Stroke Patients (EVATRISP) prospective registry. Patients treated with endovascular thrombectomy (EVT) were compared to those treated with intravenous thrombolysis (IVT). Odds ratios with 95% confidence intervals (OR; 95%CI) were calculated using multivariate regression analysis. RESULTS: Included were 92 patients with ACA-stroke. Of the 92 ACA patients, 55 (60%) were treated with IVT only and 37 (40%) with EVT (±bridging IVT). ACA patients treated with EVT had more often wake-up stroke (24% vs. 6%, p = 0.044) and proximal ACA occlusions (43% vs. 24%, p = 0.047) and tended to have higher stroke severity on admission [NIHSS: 10.0 vs 7.0, p = 0.054). However, odds for favorable outcome, mortality or symptomatic intracranial hemorrhage did not differ significantly between both groups. Exploration of the effect of clot location inside the ACA showed that in patients with A1 or A2/A3 ACA occlusions the chances of favorable outcome were not influenced by treatment allocation to IVT or EVT. DISCUSSION: Treatment with either IVT or EVT could be safe with similar effect in patients with ACA-strokes and these effects may be independent of clot location within the occluded ACA.

Editor's Choice - Very Urgent Carotid Endarterectomy is Associated with an Increased Procedural Risk: The Carotid Alarm Study.

OBJECTIVE/BACKGROUND: The aim of the Carotid Alarm Study was to compare the procedural risk of carotid endarterectomy (CEA) performed within 48 hours with that after 48 hours to 14 days following an ipsilateral cerebrovascular ischaemic event. METHODS: Consecutive patients with symptomatic carotid stenosis undergoing CEA were prospectively recruited. Time to surgery was calculated as time from the most recent ischaemic event preceding surgery. A neurologist examined patients before and, after CEA. The primary endpoint was the composite endpoint of death and/or any stroke within 30 days of the surgical procedure. The study was designed to include 600 patients, with 150 operated on within 48 hours. RESULTS: From October 2010 to December 2015, 418 patients were included, of whom 75 were operated within 48 hours of an ischaemic event. The study was prematurely terminated owing to the slow recruitment rate in the group operated on within 48 hours. Patients undergoing CEA within 48 hours had a higher risk of reaching the primary endpoint than those operated on later (8.0% vs. 2.9%). Multivariate logistic regression analyses showed that CEA performed within 48 h (odds ratio [OR] 3.07; 95% confidence interval [CI] 1.04-9.09), CEA performed out of office hours (OR 3.65; 95% CI 1.14-11.67), and use of shunt (OR 4.02; 95% CI 1.36-11.93) were all independently associated with an increased risk of reaching the primary endpoint. CONCLUSION: CEA performed within 48 hours was associated with a higher risk of complications compared with surgery performed 48 hours-14 days after the most recent ischaemic event.

Impact of the Swedish National Stroke Campaign on stroke awareness.

BACKGROUND: Time delay from stroke onset to arrival in hospital is an important obstacle to widespread reperfusion therapy. To increase knowledge about stroke, and potentially decrease this delay, a 27-month national public information campaign was carried out in Sweden. AIMS: To assess the effects of a national stroke campaign in Sweden. METHODS: The variables used to measure campaign effects were knowledge of the AKUT test [a Swedish equivalent of the FAST (Face-Arm-Speech-Time)] test and intent to call 112 (emergency telephone number) . Telephone interviews were carried out with 1500 randomly selected people in Sweden at eight points in time: before, three times during, immediately after, and nine, 13 and 21 months after the campaign. RESULTS: Before the campaign, 4% could recall the meaning of some or all keywords in the AKUT test, compared with 23% during and directly after the campaign, and 14% 21 months later. Corresponding figures were 15%, 51%, and 50% for those remembering the term AKUT and 65%, 76%, and 73% for intent to call 112 when observing or experiencing stroke symptoms. During the course of the campaign, improvement of stroke knowledge was similar among men and women, but the absolute level of knowledge for both items was higher for women at all time points. CONCLUSION: The nationwide campaign substantially increased knowledge about the AKUT test and intention to call 112 when experiencing or observing stroke symptoms, but knowledge declined post-intervention. Repeated public information therefore appears essential to sustain knowledge gains.

Risk of Recurrent Stroke in Patients with Symptomatic Mild (20-49% NASCET) Carotid Artery Stenosis.

OBJECTIVE: The objective of this study was to evaluate the risk of recurrent ischaemic stroke in patients with ultrasound assessed symptomatic mild carotid artery stenosis (20-49% NASCET) treated solely with modern medical treatment. METHOD: This was a retrospective, observational register cohort study. Three groups of patients were recruited from a database of all carotid Doppler ultrasound examinations performed in the Gothenburg region between 2004 and 2009. Patients with symptomatic mild carotid artery stenosis (n = 162) were compared with patients with asymptomatic carotid artery stenosis (n = 301) of equal degree and a group of patients with surgically (CEA) treated symptomatic moderate or severe carotid artery stenosis (n = 220). Kaplan-Meier estimates and Cox proportional hazard models were used to compare the primary outcome (ipsilateral ischaemic stroke) between groups. RESULTS: After a 3 year follow up, the cumulative incidence of recurrent ipsilateral stroke in patients with symptomatic mild carotid artery stenosis was 7.4%. Patients with symptomatic mild carotid artery stenosis had a substantially increased risk of recurrent ipsilateral stroke compared with asymptomatic patients with equal degree of stenosis (HR 5.5. 95% CI 1.8-17.1; p = .003) as also compared with patients with CEA treated symptomatic moderate or severe stenosis (HR 7.8. 95% CI 1.62-37.8; p = .011). CONCLUSIONS: The present study on patients with symptomatic mild carotid artery stenosis, as determined by Doppler ultrasound, shows that there is still a substantial risk of recurrent stroke in this group.

Risk of early recurrent stroke in symptomatic carotid stenosis.

OBJECTIVES: The risk of recurrent stroke in patients with symptomatic carotid artery stenosis is highest in the first weeks after a transient ischemic attack (TIA) or minor stroke and can be reduced with carotid endarterectomy (CEA). The optimal timing of CEA remains a controversial issue since very urgent CEA is associated with an increased procedural risk. The aim of this study was to determine the risk of very early recurrent stroke in a population with symptomatic high grade carotid stenosis. METHODS: Data were analyzed on all patients with ocular TIA, TIA, or minor stroke with >70% carotid stenosis as assessed by carotid ultrasound at Sahlgrenska University Hospital during the periods 2004-2006 and 2010-2012. The two time periods were chosen to minimize selection bias and to analyze changes over time. The risk of recurrent stroke within 30 days of the referring event was assessed. RESULTS: 397 patients with symptomatic carotid stenosis were identified. The risk of recurrent stroke in the total cohort was 2.0% (CI 95% 0.6-3.4) by day 2, 4.0% (CI 95% 2.0-5.9) by day 7, and 7.5% (CI 95% 4.4-10.6) by day 30. There was no significant difference between the two time periods. Patients with minor stroke had a significantly higher risk of recurrent stroke than patients with TIA or ocular TIA as the referring event. CONCLUSIONS: The data suggest that the early risk of recurrent stroke in symptomatic significant carotid stenosis is not as high as some earlier studies have shown. The risk is similar to several studies in which a modern medical treatment regime could be assumed.

Public stroke awareness and intent to call 112 in Sweden.

BACKGROUND AND AIMS: Recognition of stroke symptoms and activation of emergency services are essential in minimizing delay for acute stroke treatments. In this study, we assessed public stroke awareness in Sweden. METHODS: One thousand and five hundred residents aged 18-79 years participated in a telephone survey. Open-ended questions were used to assess knowledge of stroke symptoms, risk factors, and action if witnessing or experiencing a potential stroke. RESULTS: Seventy-two percentage could report at least one stroke symptom and 86% at least one risk factor. Only 13% could report three or more stroke symptoms. Female sex (OR, 1.79; 95% CI, 1.30-2.45) and high education (OR, 2.30; 95% CI, 1.38-3.80) were associated with knowledge of stroke symptoms. Sixty-five percentage indicated they would call the emergency number 112 if witnessing or experiencing a potential stroke. Female sex (OR, 1.48; 95% CI, 1.18-1.85) and high education (OR, 1.40; 95% CI, 1.01-1.93) were positively associated, while increasing age (OR, 0.99; 95% CI, 0.98-0.99) was negatively associated with intent to call 112. CONCLUSION: We confirm a rather low public awareness of stroke in Sweden, poorer among males and those with low education. With increasing age, a lower proportion indicated intent to call 112 for stroke symptoms.