RESUMO
BACKGROUND: Since the efficacy and safety of endovascular thrombectomy (EVT) in patients with acute ischemic stroke with a large infarct area is still inconclusive, we sought to compare functional and neurological outcomes with the use of endovascular thrombectomy versus medical care alone. METHODS: We searched MEDLINE (via PubMed), Embase, Cochrane Library, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP) to retrieve all the relevant randomized controlled trials (RCTs) on this topic. Review manager (RevMan) was used to perform meta-analyses using a random-effect model. Dichotomous outcomes were pooled using risk ratios (RR) with 95% confidence intervals (CIs). RESULTS: Our meta-analysis included 6 RCTs with a total of 1665 patients. Most studies included patients with an ASPECTS score of 3-5. Our results demonstrate that endovascular thrombectomy significantly increased the rates of functional independence (mRS ≤ 2) (RR, 2.49; 95% CI, 1.89-3.29) and moderate neurological outcome (mRS ≤ 3) (RR, 1.90; 95% CI, 1.50-2.40) at 90 days. The benefit of EVT for these outcomes remained the same at 1-year follow-up. Endovascular thrombectomy was associated with increased rates of early neurological improvement (RR, 2.22; 95% CI, 1.53-3.22), excellent neurological recovery (mRS ≤ 1) (RR, 1.75; 95% CI, 1.02-3.03), and decreased rate of poor neurological recovery (mRS 4-6) (RR, 0.81; 95% CI, 0.76-0.86). No significant difference was found between the two groups regarding all-cause mortality (RR, 0.86; 95% CI, 0.72-1.02), decompressive craniectomy (RR, 1.32; 95% CI, 0.89-1.94), and the incidence of serious adverse effects (RR, 1.39; 95% CI, 0.83-2.32) between the two groups. Endovascular thrombectomy significantly increased the rates of any intracranial hemorrhage (RR, 1.94; 95% CI, 1.48-2.53) and symptomatic intracranial hemorrhage (RR, 1.73; 95% CI, 1.11-2.69). CONCLUSION: Endovascular thrombectomy (EVT) significantly improves neurological and functional outcomes in patients who present within 6 hours of stroke onset with ICA and proximal M1 occlusions, and ASPECTS scores ranging from 3 to 5, compared to medical therapy alone, with an increased risk of symptomatic intracranial hemorrhage.
Assuntos
Procedimentos Endovasculares , AVC Isquêmico , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Trombectomia , Humanos , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Procedimentos Endovasculares/efeitos adversos , AVC Isquêmico/diagnóstico , AVC Isquêmico/terapia , AVC Isquêmico/fisiopatologia , AVC Isquêmico/mortalidade , AVC Isquêmico/cirurgia , Resultado do Tratamento , Fatores de Risco , Fatores de Tempo , Idoso , Masculino , Feminino , Pessoa de Meia-Idade , Estado Funcional , Avaliação da Deficiência , Idoso de 80 Anos ou maisRESUMO
OBJECTIVES: To provide an updated analysis of the burden of ischemic stroke in the United States. MATERIALS AND METHODS: Using the Global Burden of Disease database, we estimated age-standardized, population-adjusted rates of incidence, prevalence, mortality, and disability-adjusted life years from 2010 to 2019, with regional comparisons. Deaths and disability-adjusted life years were compared in 2010-2014 and 2015-2019 to assess the potential effect of increased mechanical thrombectomy use. The attributable, disability-adjusted life years for twenty risk factors were estimated, ranked, and trended. RESULTS: Incident ischemic strokes decreased by 11.4 % across the study period from 65.7 (55.9-77.3) to 58.2 (49.0-69.5) per 100,000. Prevalence (-8.2 %), mortality (-1.9 %), and disability-adjusted life years (-4.4 %) all declined. All regions showed reductions in all burden measures, with the South consistently having the highest burden yet the largest reduction in incidence (-12.6 %) and prevalence (-10.5 %). Deaths (p < 0.0001) and DALYs (p < 0.0001) significantly differed between the pre- and post-mechanical thrombectomy eras. Total attributable disability-adjusted life years for all risk factors decreased from 304.7 (258.5-353.2) in 2010 to 288.9 (242.2-337.2) in 2019. In 2019, the risk factors with the most disability-adjusted life years were hypertension, hyperglycemia, and obesity with no state-based differences. Across the study period, disability-adjusted life years attributable to leading risk factors decreased among men but decreased less or increased among women. CONCLUSIONS: The burden of ischemic stroke decreased during the study period. Declines in deaths and disability-adjusted life years suggest a mitigating impact of mechanical thrombectomy. While disability-adjusted life years attributable to leading risk factors decreased, sex-based disparities were observed.
Assuntos
Bases de Dados Factuais , AVC Isquêmico , Trombectomia , Humanos , Fatores de Risco , Estados Unidos/epidemiologia , Masculino , Feminino , AVC Isquêmico/mortalidade , AVC Isquêmico/diagnóstico , AVC Isquêmico/epidemiologia , AVC Isquêmico/terapia , Idoso , Pessoa de Meia-Idade , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Incidência , Fatores de Tempo , Prevalência , Medição de Risco , Resultado do Tratamento , Idoso de 80 Anos ou mais , Adulto , Avaliação da Deficiência , Anos de Vida Ajustados por Deficiência , Adulto JovemRESUMO
OBJECTIVES: Patients with acute ischemic stroke (AIS) often have an accumulation of pre-existing comorbidities, but its clinical impact on outcomes after mechanical thrombectomy (MT) remains unknown. Therefore, we examined whether comorbidity burden before AIS onset could predict clinical outcomes after MT. METHODS: In this retrospective cohort, we enrolled consecutive patients with community-onset AIS who underwent MT between April 2016 and December 2021. To evaluate each patient's comorbidity burden, we calculated Charlson comorbidity index (CCI), then classified the patients into the High CCI (≥ 3) and the Low CCI (< 3) groups. The primary outcome was a good neurological outcome at 90 days, defined as a modified Rankin scale 0-2 or no worse than the previous daily conditions. All-cause mortality at 90 days and hemorrhagic complications after MT were also compared between the two groups. We estimated the odds ratios and their confidence intervals using a multivariable logistic regression model. RESULTS: A total of 388 patients were enrolled, of whom 86 (22.2%) were classified into the High CCI group. Patients in the High CCI group were less likely to achieve a good neurological outcome (adjusted odds ratio of 0.26 [95% confidence interval, 0.12-0.58]). Moreover, symptomatic intracranial hemorrhage was more common in the High CCI (14.0% vs. 4.6%; adjusted odds ratio, 4.10 [95% confidence interval, 1.62-10.3]). CONCLUSIONS: Comorbidity burden assessed by CCI was associated with clinical outcomes after MT. CCI has the potential to become a simple and valuable tool for predicting neurological prognosis among patients with AIS and MT.
Assuntos
Comorbidade , AVC Isquêmico , Trombectomia , Humanos , Masculino , Estudos Retrospectivos , Feminino , Idoso , Resultado do Tratamento , Pessoa de Meia-Idade , Fatores de Risco , Fatores de Tempo , Medição de Risco , AVC Isquêmico/epidemiologia , AVC Isquêmico/diagnóstico , AVC Isquêmico/terapia , AVC Isquêmico/mortalidade , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Idoso de 80 Anos ou mais , Avaliação da Deficiência , Recuperação de Função Fisiológica , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/mortalidadeRESUMO
BACKGROUND: Our study aims to present clinical outcomes of mechanical thrombectomy (MT) in a safety-net hospital. METHODS: This is a retrospective study of intermediate or high-risk pulmonary embolism (PE) patients who underwent MT between October 2020 and May 2023. The primary outcome was 30-day mortality. RESULTS: Among 61 patients (mean age 57.6 years, 47% women, 57% Black) analyzed, 12 (19.7%) were classified as high-risk PE, and 49 (80.3%) were intermediate-risk PE. Of these patients, 62.3% had Medicaid or were uninsured, 50.8% lived in a high poverty zip code. The prevalence of normotensive shock in intermediate-risk PE patients was 62%. Immediate hemodynamic improvements included 7.4 mmHg mean drop in mean pulmonary artery pressure (-21.7%, p < 0.001) and 93% had normalization of their cardiac index postprocedure. Thirty-day mortality for the entire cohort was 5% (3 patients) and 0% when restricted to the intermediate-risk group. All 3 patients who died at 30 days presented with cardiac arrest. There were no differences in short-term mortality based on race, insurance type, citizenship status, or socioeconomic status. All-cause mortality at most recent follow up was 13.1% (mean follow up time of 13.4 ± 8.5 months). CONCLUSION: We extend the findings from prior studies that MT demonstrates a favorable safety profile with immediate improvement in hemodynamics and a low 30-day mortality in patients with acute PE, holding true even with relatively higher risk and more vulnerable population within a safety-net hospital.
Assuntos
Embolia Pulmonar , Provedores de Redes de Segurança , Trombectomia , Humanos , Feminino , Masculino , Embolia Pulmonar/mortalidade , Embolia Pulmonar/fisiopatologia , Embolia Pulmonar/terapia , Embolia Pulmonar/diagnóstico , Estudos Retrospectivos , Pessoa de Meia-Idade , Resultado do Tratamento , Fatores de Risco , Idoso , Fatores de Tempo , Medição de Risco , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Doença Aguda , Adulto , HemodinâmicaRESUMO
BACKGROUND: Our aim was to compare the outcomes of treatment with endovascular thrombectomy for pre-stroke dependent versus pre-stroke independent among the very elderly ≥90 years. METHODS: A retrospective cohort study was performed on 106 patients ≥90 years who underwent endovascular thrombectomy for ischaemic stroke in Western Australia between June 2016 and September 2021. Patient, stroke and procedural details along with inpatient progress and outcome at 90 days were recorded. Patients were divided into Group A (pre-stroke modified Rankin Scale 0-2) and Group B (pre-stroke modified Rankin Scale >2). Primary outcome measure was functional status at 90 days post-stroke, with favourable clinical outcome defined as a 90-day mRS category equal to the patients' respective pre-stroke mRS category. Secondary outcome measures include successful reperfusion, symptomatic intracranial haemorrhage, hospital length-of-stay, change in accommodation to an aged care facility, and mortality during admission, at 90 days and one year. RESULTS: 61 patients were allocated to Group A and 45 to Group B. There was none with pre-stroke mRS 5. Group B had more pre-existing cognitive impairment, aged care facility residents, higher median age and lower Alberta Stroke Program Early CT Score. For primary outcome measure, 38 % of patients in Group A and 49 % in Group B achieved a favourable clinical outcome. The difference was not significant (p=0.3408). For secondary outcome measures, Group B had a significantly higher 90-day mortality rate at 47 % versus 24 % in Group A (p=0.03). All other secondary outcome measures were similar between the two groups. These include the rate of successful reperfusion and symptomatic intracranial haemorrhage, hospital length-of-stay, new transition into an aged care facility, inpatient mortality rate and 1-year mortality rate. CONCLUSION: When treated with endovascular thrombectomy for ischaemic stroke, nonagenarians with pre-existing dependency achieved a rate of favourable functional outcome comparable with their independent peers, although they also had higher 90-day mortality rate.
Assuntos
Avaliação da Deficiência , Procedimentos Endovasculares , Estado Funcional , AVC Isquêmico , Recuperação de Função Fisiológica , Trombectomia , Humanos , Masculino , Feminino , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Idoso de 80 Anos ou mais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Estudos Retrospectivos , Resultado do Tratamento , AVC Isquêmico/mortalidade , AVC Isquêmico/diagnóstico , AVC Isquêmico/terapia , AVC Isquêmico/fisiopatologia , AVC Isquêmico/cirurgia , Fatores de Tempo , Fatores de Risco , Fatores Etários , Austrália Ocidental , Tempo de Internação , Medição de RiscoRESUMO
INTRODUCTION: Renal cell carcinoma (RCC) has been associated with an increased risk for acute ischemic stroke (AIS). As individuals with cancer who experience AIS tend to face higher mortality rates compared to AIS patients without cancer, recognizing the implications of RCC in AIS is crucial for identifying high-risk patients for major complications and directing management strategies. OBJECTIVE: To examine risk factors, interventions, and outcomes for patients with AIS stratified by their RCC diagnosis. METHODS: The National Inpatient Sample (NIS) database was queried for the period 2010-2019 using International Classification of Disease 10th Edition (ICD-10) codes for acute ischemic stroke and renal malignancies. We assessed demographic information, comorbidities, and clinical interventions between patients presenting with AIS, with and without renal malignancies. A logistic regression model was employed to further examine mortality outcomes. RESULTS: Among 1,609,817 patients identified with AIS, 2,068 (0.12%) had a concomitant diagnosis of RCC. AIS patients with RCC were older (72.09 yrs. vs. 70.9 yrs., p < 0.01), more often white (72.05% vs. 68.16%, p < 0.01), and had similar stroke severity scores. RCC patients received less tissue plasminogen activator (tPA; 4.98% vs. 6.2%, p = 0.02) but underwent endovascular mechanical thrombectomy (MT) at similar rates. RCC patients had more complications (p < 0.01) as well as longer hospital stays (8.19 days vs. 5.98 days, p < 0.01), and higher rates of mortality (11.27% vs. 5.63%, p < 0.01), when compared to their non-RCC counterparts. Propensity score-adjusted analysis largely confirmed these findings, with RCC being positively associated with in-hospital mortality (OR: 1.373, p < 0.01) and longer stays (OR: 2.591, p < 0.01). CONCLUSION: In addition to describing the demographics and clinical course of AIS patients diagnosed with RCC, our study underscores the substantial impact of RCC on AIS outcomes. Despite experiencing strokes of similar severity, AIS patients diagnosed with RCC are at a heightened risk of complications, including thromboembolic events and infections, leading to elevated in-hospital mortality rates and prolonged hospital stays.
Assuntos
Carcinoma de Células Renais , Bases de Dados Factuais , AVC Isquêmico , Neoplasias Renais , Humanos , Carcinoma de Células Renais/mortalidade , Carcinoma de Células Renais/terapia , Carcinoma de Células Renais/diagnóstico , Carcinoma de Células Renais/complicações , Masculino , Feminino , Idoso , Neoplasias Renais/mortalidade , Neoplasias Renais/terapia , Neoplasias Renais/diagnóstico , Neoplasias Renais/epidemiologia , Fatores de Risco , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , AVC Isquêmico/mortalidade , AVC Isquêmico/terapia , AVC Isquêmico/diagnóstico , AVC Isquêmico/epidemiologia , Resultado do Tratamento , Medição de Risco , Idoso de 80 Anos ou mais , Fatores de Tempo , Estudos Retrospectivos , Terapia Trombolítica/mortalidade , Terapia Trombolítica/efeitos adversos , Mortalidade Hospitalar , Trombectomia/mortalidade , Trombectomia/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidadeRESUMO
Importance: Use of oral vitamin K antagonists (VKAs) may place patients undergoing endovascular thrombectomy (EVT) for acute ischemic stroke caused by large vessel occlusion at increased risk of complications. Objective: To determine the association between recent use of a VKA and outcomes among patients selected to undergo EVT in clinical practice. Design, Setting, and Participants: Retrospective, observational cohort study based on the American Heart Association's Get With the Guidelines-Stroke Program between October 2015 and March 2020. From 594 participating hospitals in the US, 32â¯715 patients with acute ischemic stroke selected to undergo EVT within 6 hours of time last known to be well were included. Exposure: VKA use within the 7 days prior to hospital arrival. Main Outcome and Measures: The primary end point was symptomatic intracranial hemorrhage (sICH). Secondary end points included life-threatening systemic hemorrhage, another serious complication, any complications of reperfusion therapy, in-hospital mortality, and in-hospital mortality or discharge to hospice. Results: Of 32â¯715 patients (median age, 72 years; 50.7% female), 3087 (9.4%) had used a VKA (median international normalized ratio [INR], 1.5 [IQR, 1.2-1.9]) and 29â¯628 had not used a VKA prior to hospital presentation. Overall, prior VKA use was not significantly associated with an increased risk of sICH (211/3087 patients [6.8%] taking a VKA compared with 1904/29â¯628 patients [6.4%] not taking a VKA; adjusted odds ratio [OR], 1.12 [95% CI, 0.94-1.35]; adjusted risk difference, 0.69% [95% CI, -0.39% to 1.77%]). Among 830 patients taking a VKA with an INR greater than 1.7, sICH risk was significantly higher than in those not taking a VKA (8.3% vs 6.4%; adjusted OR, 1.88 [95% CI, 1.33-2.65]; adjusted risk difference, 4.03% [95% CI, 1.53%-6.53%]), while those with an INR of 1.7 or lower (n = 1585) had no significant difference in the risk of sICH (6.7% vs 6.4%; adjusted OR, 1.24 [95% CI, 0.87-1.76]; adjusted risk difference, 1.13% [95% CI, -0.79% to 3.04%]). Of 5 prespecified secondary end points, none showed a significant difference across VKA-exposed vs VKA-unexposed groups. Conclusions and Relevance: Among patients with acute ischemic stroke selected to receive EVT, VKA use within the preceding 7 days was not associated with a significantly increased risk of sICH overall. However, recent VKA use with a presenting INR greater than 1.7 was associated with a significantly increased risk of sICH compared with no use of anticoagulants.
Assuntos
Isquemia Encefálica , Procedimentos Endovasculares , Hemorragias Intracranianas , AVC Isquêmico , Trombectomia , Vitamina K , Idoso , Feminino , Humanos , Masculino , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/mortalidade , Isquemia Encefálica/cirurgia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/mortalidade , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Fibrinolíticos/uso terapêutico , Hemorragia/induzido quimicamente , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/etiologia , AVC Isquêmico/tratamento farmacológico , AVC Isquêmico/mortalidade , AVC Isquêmico/cirurgia , Estudos Retrospectivos , Trombectomia/efeitos adversos , Trombectomia/métodos , Trombectomia/mortalidade , Resultado do Tratamento , Vitamina K/antagonistas & inibidores , Administração Oral , Mortalidade Hospitalar , Coeficiente Internacional NormatizadoRESUMO
OBJECTIVE: Catheter-directed interventions (CDIs) are commonly performed for acute pulmonary embolism (PE). The evolving catheter types and treatment algorithms impact the use and outcomes of these interventions. This study aimed to investigate the changes in CDI practice and their impact on outcomes. METHODS: Patients who underwent CDIs for PE between 2010 and 2019 at a single institution were identified from a prospectively maintained database. A PE team was launched in 2012, and in 2014 was established as an official Pulmonary Embolism Response Team. CDI annual use trends and clinical failures were recorded. Clinical success was defined as physiologic improvement in the absence of major bleeding, perioperative stroke or other procedure-related adverse event, decompensation for submassive or persistent shock for massive PE, the need for surgical thromboembolectomy, or death. Major bleeding was defined as requiring a blood transfusion, a surgical intervention, or suffering from an intracranial hemorrhage. RESULTS: There were 372 patients who underwent a CDI for acute PE during the study period with a mean age of 58.9 ± 15.4 years; there were males 187 (50.3%) and 340 patients has a submassive PE (91.4%). CDI showed a steep increase in the early Pulmonary Embolism Response Team years, peaking in 2016 with a subsequent decrease. Ultrasound-assisted thrombolysis was the predominant CDI technique peaking at 84% of all CDI in 2014. Suction thrombectomy use peaked at 15.2% of CDI in 2019. The mean alteplase dose with catheter thrombolysis techniques decreased from 26.8 ± 12.5 mg in 2013 to 13.9 ± 7.5 mg in 2019 (P < .001). The mean lysis time decreased from 17.2 ± 8.3 hours in 2013 to 11.3 ± 8.2 hours in 2019 (P < .001). Clinical success for the massive and the submassive PE cohorts was 58.1% and 91.2%, respectively; the major bleed rates were 25.0% and 5.3%. There were two major clinical success peaks, one in 2015 mirroring our technical learning curve and one in 2019 mirroring our patient selection learning curve. The clinical success decrease in 2018 was primarily derived from blood transfusions owing to acute blood loss during suction thrombectomy. CONCLUSIONS: CDIs for acute PE have rapidly evolved with high success rates. Multidisciplinary approaches among centers with appropriate expertise are advisable for the safe and successful implementation of catheter interventions.
Assuntos
Cateterismo de Swan-Ganz/tendências , Procedimentos Endovasculares/tendências , Padrões de Prática Médica/tendências , Embolia Pulmonar/terapia , Trombectomia/tendências , Terapia Trombolítica/tendências , Adulto , Idoso , Transfusão de Sangue/tendências , Cateterismo de Swan-Ganz/efeitos adversos , Cateterismo de Swan-Ganz/mortalidade , Bases de Dados Factuais , Embolectomia/tendências , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Hemostasia Cirúrgica/tendências , Humanos , Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/terapia , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/mortalidade , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Monitored anesthesia care (MAC) and general anesthesia (GA) with endotracheal intubation are the 2 most used techniques for patients with acute ischemic stroke (AIS) undergoing endovascular thrombectomy. We aimed to test the hypothesis that increased arterial oxygen concentration during reperfusion period is a mechanism underlying the association between use of GA (versus MAC) and increased risk of in-hospital mortality. METHODS: In this retrospective cohort study, data were collected at the Cleveland Clinic between 2013 and 2018. To assess the potential mediation effect of time-weighted average oxygen saturation (Spo2) in first postoperative 48 hours between the association between GA versus MAC and in-hospital mortality, we assessed the association between anesthesia type and post-operative Spo2 tertiles (exposure-mediator relationship) through a cumulative logistic regression model and assessed the association between Spo2 and in-hospital mortality (mediator-outcome relationship) using logistic regression models. Confounding factors were adjusted for using propensity score methods. Both significant exposure-mediator and significant mediator-outcome relationships are needed to suggest potential mediation effect. RESULTS: Among 358 patients included in the study, 104 (29%) patients received GA and 254 (71%) received MAC, with respective hospital mortality rate of 19% and 5% (unadjusted P value <.001). GA patients were 1.6 (1.2, 2.1) (P < .001) times more likely to have a higher Spo2 tertile as compared to MAC patients. Patients with higher Spo2 tertile had 3.8 (2.1, 6.9) times higher odds of mortality than patients with middle Spo2 tertile, while patients in the lower Spo2 tertile did not have significant higher odds compared to the middle tertile odds ratio (OR) (1.8 [0.9, 3.4]; overall P < .001). The significant exposure-mediator and mediator-outcome relationships suggest that Spo2 may be a mediator of the relationship between anesthetic method and mortality. However, the estimated direct effect of GA versus MAC on mortality (ie, after adjusting for Spo2; OR [95% confidence interval {CI}] of 2.1 [0.9-4.9]) was close to the estimated association ignoring Spo2 (OR [95% CI] of 2.2 [1.0-5.1]), neither statistically significant, suggesting that Spo2 had at most a modest mediator role. CONCLUSIONS: GA was associated with a higher Spo2 compared to MAC among those treated by endovascular thrombectomy for AIS. Spo2 values that were higher than the middle tertile were associated with higher odds of mortality. However, GA was not significantly associated with higher odds of death. Spo2 at most constituted a modest mediator role in explaining the relationship between GA versus MAC and mortality.
Assuntos
Isquemia Encefálica/mortalidade , Procedimentos Endovasculares/mortalidade , Mortalidade Hospitalar/tendências , AVC Isquêmico/mortalidade , Saturação de Oxigênio/fisiologia , Trombectomia/mortalidade , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/cirurgia , Estudos de Coortes , Procedimentos Endovasculares/tendências , Feminino , Humanos , AVC Isquêmico/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Trombectomia/tendências , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: The short-term benefits of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) have been widely documented, yet there is limited evidence to show that this is sustained in the long term. We aimed to determine whether the benefit of EVT on functional outcome at 3 months is maintained at 12 months and the factors correlating with functional independence and quality of life. METHODS: Data for analysis came from a prospective registry of consecutive patients undergoing EVT at a single Comprehensive Stroke Center (Oct 2018-Sep 2019). A phone interview was conducted for 12-month patient outcomes. Functional outcome was assessed by the modified Rankin Scale (mRS). Quality of life was determined by return to usual place of residence, work, or driving and calculation of a health utility index using the European Quality of Life-5 Dimensions questionnaire (EQ-5D-3L). RESULTS: Of the 151 patients who underwent EVT during the study period, 12-month follow-up was available for 145 (96%). At 12 months, 44% (n = 64) of patients were functionally independent (mRS 0-2) compared to 48% at 3 months. Mortality at 12 months was 26% compared to 17% at 3 months. Significant predictors of functional independence at 12 months were younger age and lower baseline National Institutes of Health Stroke Scale. Better quality of life significantly correlated with return to usual place of residence and driving. CONCLUSION: Three-month functional independence was sustained at 12 months, indicating that EVT remains beneficial for patients with AIS in the longer term.
Assuntos
Procedimentos Endovasculares , AVC Isquêmico/terapia , Trombectomia , Idoso , Idoso de 80 Anos ou mais , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Estado Funcional , Humanos , AVC Isquêmico/diagnóstico , AVC Isquêmico/mortalidade , AVC Isquêmico/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Qualidade de Vida , Recuperação de Função Fisiológica , Sistema de Registros , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: The aim of this study was to test the hypothesis that endovascular aspiration thrombectomy of right atrial thrombus (RAT) using the AngioVac device is as safe and effective in patients with cancer as those without cancer. BACKGROUND: RAT is a uniquely challenging clinical presentation of venous thromboembolism due to its low incidence and historically high-risk of mortality due to thrombus propagation into the pulmonary arteries. There is a lack of consensus regarding management, particularly in high-risk cancer patients. Endovascular aspiration thrombectomy utilizing the AngioVac device is effective in removal of right atrial thrombus and may be a safer option for patients with cancer in whom avoidance of higher-risk intervention is preferred. METHODS: This was an institutional review board-approved retrospective single-center case control study of patients with RAT who underwent AngioVac aspiration thrombectomy between August 2013 and July 2020. Analysis of patient demographics and clinical characteristics, thrombus-related factors, and operative details was performed. Primary endpoints included survival, safety, and technical success. RESULTS: A total of 44 patients met inclusion criteria, 20 of whom with active malignancy. The oncology group had a significantly higher Charlson comorbidity index (P = 0.01). Comparative outcomes between the oncology and non-oncology group showed no difference in survival (P = 0.8) or technical success (OR 3, 95% CI 0.83-10.9). There were 9 complications, including 6 minor, 1 moderate, 1 severe, and 1 death. CONCLUSIONS: AngioVac aspiration thrombectomy of RAT is as safe and effective in patients with cancer as those without cancer.
Assuntos
Cardiopatias/terapia , Neoplasias/complicações , Trombectomia/instrumentação , Trombose/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Cardiopatias/complicações , Cardiopatias/diagnóstico por imagem , Cardiopatias/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/diagnóstico , Neoplasias/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Trombose/complicações , Trombose/diagnóstico por imagem , Trombose/mortalidade , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVES: With growing evidence of its efficacy for patients with large-vessel occlusion (LVO) ischemic stroke, the use of endovascular thrombectomy (EVT) has increased. The "weekend effect," whereby patients presenting during weekends/off hours have worse clinical outcomes than those presenting during normal working hours, is a critical area of study in acute ischemic stroke (AIS). Our objective was to evaluate whether a "weekend effect" exists in patients undergoing EVT. METHODS: This retrospective, cross-sectional analysis of the 2016-2018 Nationwide Inpatient Sample data included patients ≥18 years with documented diagnosis of ischemic stroke (ICD-10 codes I63, I64, and H34.1), procedural code for EVT, and National Institutes of Health Stroke Scale (NIHSS) score; the exposure variable was weekend vs. weekday treatment. The primary outcome was in-hospital death; secondary outcomes were favorable discharge, extended hospital stay (LOS), and cost. Logistic regression models were constructed to determine predictors for outcomes. RESULTS: We identified 6052 AIS patients who received EVT (mean age 68.7±14.8 years; 50.8% female; 70.8% White; median (IQR) admission NIHSS 16 (10-21). The primary outcome of in-hospital death occurred in 560 (11.1%); the secondary outcome of favorable discharge occurred in 1039 (20.6%). The mean LOS was 7.8±8.6 days. There were no significant differences in the outcomes or cost based on admission timing. In the mixed-effects models, we found no effect of weekend vs. weekday admission on in-hospital death, favorable discharge, or extended LOS. CONCLUSION: These results demonstrate that the "weekend effect" does not impact outcomes or cost for patients who undergo EVT for LVO.
Assuntos
Plantão Médico , Procedimentos Endovasculares , AVC Isquêmico/terapia , Trombectomia , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/mortalidade , Feminino , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Pacientes Internados , AVC Isquêmico/diagnóstico , AVC Isquêmico/economia , AVC Isquêmico/mortalidade , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Trombectomia/efeitos adversos , Trombectomia/economia , Trombectomia/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
OBJECTIVES: To determine the outcomes and feasibility of endovascular treatment, mainly based on manual aspiration thrombectomy (MAT) with adjunctive percutaneous balloon angioplasty with or without stent deployment, for treatment of symptomatic ilio-femoral deep vein thrombosis (IFDVT) in cancer patients. MATERIALS AND METHODS: In this retrospective cohort study, 135 consecutive patients (56 men; mean age, 63 years; 149 limbs) with acute (n = 113; 83.7%) and subacute to chronic (n = 22; 16.3%) symptomatic IFDVT underwent MAT-based endovascular treatment. Among them, adjunctive balloon angioplasty and stent placement was performed in 94 patients. Technical and clinical success regarding stage and cause of DVT was assessed. RESULTS: Technical success (complete thrombus removal without residual thrombus or stenosis) was achieved in 89.6%, and subjective symptom improvement was stated by 71.5% of treated patients. The primary patency rates were 88.1%, 81.6%, 76.0%, 74.1% and 69.1% at 1, 3, 6, 12, and 30 months, respectively. Recurrent IFDVT occurred in 19.3% (26/135) of patients, 0.79 cases per patients-years of follow up. According to the analysis by causes of IFDVT, recurrence rate was 19.3% (11/57), 21.2% (12/57), and 14.3% (3/21) in unknown, compression/invasion of the vein by cancerous mass, and May-Thurner syndrome groups, respectively (p = 0.798). No procedure-related complication developed. CONCLUSIONS: Endovascular treatment based on MAT is a feasible treatment option with favorable outcomes and minimal risk of complication in cancer patients with symptomatic IFDVT.
Assuntos
Neoplasias/complicações , Trombectomia/mortalidade , Trombose Venosa/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Trombectomia/métodos , Trombose Venosa/etiologia , Trombose Venosa/patologiaRESUMO
OBJECTIVES: This study assessed the temporal trends in the incidence of ischemic stroke among patients hospitalized with takotsubo cardiomyopathy (TCM) stratified by the subtypes of ischemic stroke (cardioembolic versus thrombotic). Predictors of each stroke subtype, the association with atrial fibrillation (AF), the occurrence of ventricular fibrillation/ventricular tachycardia (VF/VT), cardiogenic shock (CS), in-hospital mortality, length of stay (LOS), and total healthcare cost were also assessed. BACKGROUND: Ischemic stroke in TCM is thought to be primarily cardioembolic from left ventricular mural thromboembolism. Limited data are available on the incidence of thrombotic ischemic stroke in TCM. MATERIALS AND METHODS: We identified 27,970 patients hospitalized with the primary diagnosis of TCM from the 2008 to 2017 National Inpatient Sample, of which 751 (3%) developed ischemic stroke. Of those with ischemic stroke, 571 (76%) had thrombotic stroke while 180 (24%) had cardioembolic stroke. Cochrane armitage test was used to assess the incidence of thrombotic and cardioembolic strokes and multivariate regression was used to identify risk factors associated with each stroke subtype. We compared the incidence of AF, VF/VT, CS, LOS, in-hospital mortality and total cost between hospitalized patients with TCM alone to those with cardioembolic and thrombotic strokes. RESULTS: From 2008 - 2017, the incidence of thrombotic stroke (4.7%-9.5% (p< 0.0001) increased while it was unchanged for cardioembolic stroke (0.5%-0.7% P=0.5). In the multivariate regression, peripheral artery disease, prior history of stroke, and hyperlipidemia were significantly associated with thrombotic stroke, while CS, AF, and Asian race (compared to White race) were associated with cardioembolic stroke. Both cardioembolic and thrombotic strokes were associated with higher odds of IHM, AF, CS, longer LOS and increased cost. Trends in in-hospital mortality and the utilization of thrombolysis, cerebral angiography, and mechanical thrombectomy among patients with TCM and ischemic stroke were unchanged from 2008 to 2017. CONCLUSION: Among patients with TCM and ischemic stroke, thrombotic stroke was more common compared to cardioembolic stroke. Ischemic stroke was associated with poorer outcomes, including higher in-hospital mortality and increased healthcare resource utilization in TCM.
Assuntos
AVC Embólico/epidemiologia , Hospitalização/tendências , Cardiomiopatia de Takotsubo/epidemiologia , AVC Trombótico/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Angiografia Cerebral/tendências , Bases de Dados Factuais , AVC Embólico/diagnóstico , AVC Embólico/mortalidade , AVC Embólico/terapia , Feminino , Custos de Cuidados de Saúde/tendências , Mortalidade Hospitalar/tendências , Humanos , Incidência , Pacientes Internados , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Cardiomiopatia de Takotsubo/diagnóstico , Cardiomiopatia de Takotsubo/mortalidade , Cardiomiopatia de Takotsubo/terapia , Trombectomia/economia , Trombectomia/mortalidade , Trombectomia/tendências , AVC Trombótico/diagnóstico , AVC Trombótico/mortalidade , AVC Trombótico/terapia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND AND PURPOSE: Acute strokes due to large vessel occlusion in hospitalized patients is not uncommon. We performed a systematic review and meta-analysis to investigate the timing and outcome of endovascular thrombectomy (EVT) for in-hospital stroke. METHODS: We conducted a meta-analysis of clinical studies published in English until September 2020 in the MEDLINE and Cochrane databases. Studies reporting original data on the characteristics and outcomes of in-hospital stroke patients treated with EVT were included. We extracted data on the time-metrics from last known well (LKW) until reperfusion was achieved. We also collected data on procedural and functional outcomes. RESULTS: Out of 5093 retrieved studies, 8 were included (2,622 patients). The median age was 71.4 years and median NIHSS score on admission was 16. Patients were mostly admitted to the cardiology service (27.3%). The pooled time from LKW to recognition by staff was 72.9 min (95% CI: 40.7 to 105 min). 25.6% received IV tPA. The mean time from stroke recognition to arterial puncture was 134.5 min (95% CI: 94.9 to 174.1). Successful reperfusion occurred in 82.8.% with a pooled mean time from detection to reperfusion of 193.1 min (95% CI: 139.5 to 246.7). The 90-day independent functional outcome was reported in 42% of patients (95% CI 29 to 55%). CONCLUSION: EVT can be performed safely and successfully for in-hospital strokes. Noticeable delays from LKW to detection and then to puncture are noted. This calls for better stroke pathways to identify and treat these patients. BACKGROUND: Stroke in hospitalized patients, referred to as in-hospital stroke (IHS), accounts for 2.2-17% of all strokes.1 The majority of these are ischemic while intracranial hemorrhage represents 2-11% of all IHS.1 These patients are expected to have a rapid diagnosis and treatment given the ongoing medical supervision, and therefore favorable outcomes.1-3 However, existing studies report poor outcomes in patients with IHS with a mortality risk that exceeds that of community-onset stroke (COS): 24.7% vs 9.6%.4 Surviving IHS patients are also less likely to be discharged home compared to COS (27.7% vs 49.9%) and to be functionally independent at 3 months (31.0% vs 50.4%).1-4.
Assuntos
Atenção à Saúde , Procedimentos Endovasculares , Avaliação de Processos e Resultados em Cuidados de Saúde , Acidente Vascular Cerebral/terapia , Trombectomia , Tempo para o Tratamento , Idoso , Idoso de 80 Anos ou mais , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Fatores de Tempo , Resultado do Tratamento , Fluxo de TrabalhoRESUMO
OBJECTIVES: Pre-stroke dependency (PSD) is associated with poor outcome after stroke. The aim of the study was to evaluate the clinical outcomes and safety of mechanical thrombectomy (MT) in pre-stroke dependent patients compared to pre-stroke independent patients. MATERIAL AND METHODS: We included consecutive patients with anterior circulation acute ischaemic stroke related to large vessel occlusion (AIS-LVO), treated by MT between January 1st 2015 and July 1st 2018 in our single comprehensive stroke center. PSD was defined as a mRS score of 3 to 5 before stroke onset. We studied outcome variables in pre-stroke dependent vs. independent patients, by using logistic regression models. Clinical outcomes included clinical favorable outcome at 3 months (defined as modified Rankin Score 0-2 or equal to pre-stroke mRS score), successful recanalization rates and safety outcomes. RESULTS: Of 922 patients with anterior circulation AIS-LVO, 155 (16.8%) had PSD. Favorable outcome was less often achieved in patients with PSD (25.8% vs. 44.7%, p <0.001); but the difference did not remain significant in multivariable analysis (adjusted OR, 0.70; 95%CI, 0.44 to 1.12). Mortality at 90-days was significantly higher in patients with PSD (49.0% vs. 18.8%, adjusted OR, 2.63; 95%CI, 1.69 to 4.00). Successful recanalization was strongly associated with favorable outcome (adjusted OR, 8.15; 95%CI 4.97 to 13.34). CONCLUSIONS: One out of four patients with PSD had a favorable outcome after MT. Despite higher mortality rates compared to pre-stroke independent patients, PSD alone should not be used alone to deny mechanical thrombectomy.
Assuntos
Avaliação da Deficiência , Estado Funcional , AVC Isquêmico/terapia , Trombectomia , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Feminino , Humanos , AVC Isquêmico/diagnóstico , AVC Isquêmico/mortalidade , AVC Isquêmico/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: The time from onset to reperfusion is associated with clinical outcomes in acute ischemic stroke due to large vessel occlusion (LVO); nevertheless, the time limit of the continuing procedure remains unclear. We analyzed the relationship between procedure time and clinical outcomes in patients with LVO who underwent endovascular treatment (EVT). METHODS: We assessed 1,247 patients who underwent EVT for LVO. Data were obtained from our multicenter registry, and patients were included if data on procedure time were available. Multivariate analysis was performed to assess the impact of procedure time on clinical outcomes using the following parameters: favorable outcome (the modified Rankin score of 0-2 at 90 days), mortality within 90 days, symptomatic intracranial hemorrhage within 72 h after stroke onset, and procedure-related complications. RESULTS: The rate of favorable outcomes linearly decreased with increasing procedure time, but there was no linear relationship between procedure time and other outcomes. The adjusted odds ratio for 30-minute delay in procedure time was 0.76 (95% confidence interval, 0.68-0.84) for favorable outcome, 1.15 (0.97-1.36) for mortality, 1.08 (0.87-1.33) for symptomatic intracranial hemorrhage, and 0.92 (0.75-1.16) for complications. Significant interactions in the effect of procedure time on favorable outcome were observed between the subgroups stratified by age (≥75 or <75 years). Younger patients had a greater deleterious effect of delayed reperfusion. CONCLUSIONS: Increasing procedure time was associated with less favorable outcomes, but not with the rate of mortality, symptomatic intracerebral hemorrhage, or complications in our cohort.
Assuntos
Procedimentos Endovasculares , AVC Isquêmico/terapia , Trombectomia , Idoso , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , AVC Isquêmico/diagnóstico , AVC Isquêmico/mortalidade , AVC Isquêmico/fisiopatologia , Japão , Masculino , Sistema de Registros , Medição de Risco , Fatores de Risco , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: We performed a systematic review and meta-analysis to investigate the clinical significance of hyperdense area after thrombectomy in patients with acute ischemic stroke (AIS). METHODS: We searched Ovid MEDLINE(R) and Epub Ahead of Print, In-Process and other Non-Indexed, Cochrane Library Clinical Controlled Trials and Embase from inception to September 2020 and collected the cohort and case-control studies about the clinical significance of hyperdense area on different types of computed tomography (CT) after thrombectomy in patients with AIS. Outcomes were poor functional outcome (modified Rankin Scale [mRS] Score 3-6 at discharge or 90-day), mortality and subtypes of hemorrhage according to the European Cooperative Acute Stroke Study (ECASS). RESULTS: 1,999 patients from 16 studies were included in this meta-analysis. Pooled results indicated higher risk of symptomatic intracerebral hemorrhage (odds ratio [OR] = 3.02; 95% confidence interval [CI] 1.84-4.95; p < 0.0001, I2 = 0%) in patients with hyperdense area, and the subtype of parenchymal hematoma as well. There was also higher odds of poor functional outcome based on the mRS 3-6 at discharge or 90-day (OR = 1.92; 95% CI 1.35-2.73; p = 0.0003, I2 = 31%) and mortality (OR = 2.06; 95% CI 1.41-3.02; p = 0.0002, I2 = 0%) in patients with hyperdense area after thrombectomy compared with those without hyperdense area. CONCLUSIONS: Our results indicated that the presence of hyperdense area on CT after thrombectomy was associated with high risk of symptomatic intracerebral hemorrhage, poor functional outcome, as well as mortality in patients with AIS. However, further studies were needed to confirm these results. The meta-analysis was conducted in adherence with the PRISMA Statement and was registered at the International Prospective Register of Systematic Reviews (CRD42020164165). To the best of our knowledge, this study is the first meta-analysis investigating the effect of hyperdense area after endovascular therapy in patients with AIS.
Assuntos
Hemorragia Cerebral/diagnóstico por imagem , Circulação Cerebrovascular , Procedimentos Endovasculares , AVC Isquêmico/terapia , Trombectomia , Tomografia Computadorizada por Raios X , Adulto , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral/etiologia , Hemorragia Cerebral/mortalidade , Hemorragia Cerebral/fisiopatologia , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Estado Funcional , Humanos , AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/mortalidade , AVC Isquêmico/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: The effectiveness of mechanical thrombectomy (MT) for acute basilar artery occlusion (ABAO) remains unknown. We evaluated the feasibility, safety, and efficacy of endovascular treatment for ABAO. METHODS: We retrospectively investigated patients with ABAO who underwent MT using modern stent retrievers and an aspiration device between January 2015 and March 2019 at 12 comprehensive stroke centers. Functional outcomes and 90-day mortality rates were analyzed as primary outcomes. Factors influencing outcomes were analyzed as secondary outcomes. Relationships between outcome and affected area of infarction on arrival were also analyzed. RESULTS: Seventy-three patients were included. Good outcome (modified Rankin Scale (mRS) score 0-2) was achieved in 25/73 patients (34.2%) and the all-cause 90-day mortality rate was 23.3% (17/73). Successful recanalization (modified Thrombolysis In Cerebral Infarction grade 2b and 3) was achieved in 70/73 patients (95.9%). In univariate analyses, age, National Institutes of Health Stroke Scale score, and posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) differed significantly between good and poor functional outcome groups. Age and pc-ASPECTS were significantly associated with functional outcomes in the logistic regression model. Positive findings for the midbrain on diffusion-weighted imaging on pc-ASPECTS and brainstem score were significantly associated with poor outcomes. CONCLUSION: MT with modern devices for ABAO resulted in highly successful recanalization and good outcomes. A positive finding for the midbrain on initial imaging might predict poor outcomes. Further studies are required to confirm our results.
Assuntos
Procedimentos Endovasculares/métodos , Sistema de Registros , Trombectomia/métodos , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/cirurgia , Idoso , Idoso de 80 Anos ou mais , Artéria Basilar/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética/métodos , Imagem de Difusão por Ressonância Magnética/mortalidade , Imagem de Difusão por Ressonância Magnética/tendências , Procedimentos Endovasculares/mortalidade , Procedimentos Endovasculares/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Trombectomia/mortalidade , Trombectomia/tendências , Resultado do Tratamento , Insuficiência Vertebrobasilar/mortalidadeRESUMO
OBJECTIVE: The goal of this study is to understand how very elderly patients (VEP) after ischemic stroke are currently treated in a Stroke Unit (SU) Hub in Italy. We designed a retrospective monocentric study on patients admitted in the SU of "AO San Camillo Forlanini" over an 8-year period. MATERIAL AND METHODS: Data were collected among patients with acute ischemic stroke admitted to SU between January 2012 and December 2019. Patients were divided into three sub-groups: Adults (18-65 years); Elderly (66-85 years); and VEP (>85 years). Vascular risk factors and clinical variables as predictors of short-term clinical outcome were compared among age groups. RESULTS: A total of 1979 patients were enrolled, 254 were VEP (12.8%). The proportion of VEP showed no significant modifications during the 8-year period (11.9% in 2012-2015 and 13.7% in 2016-2019; p=0.93). The proportion of women, hypertension and atrial fibrillation was significantly higher in VEP compared to other age groups (p<0.001). The rate of VEP being treated with rt-PA increased from 2012-2015 to 2016-2019 (from 12.8% to 25.5%, p<0.001). Endovascular thrombectomy was rarely performed in VEP (1.5% of VEP). Rt-PA treatment was associated with favorable outcome for all three age groups (p<0.05). CONCLUSIONS: We showed that VEP present different vascular risk factor profiles, clinical features, and prognostic elements for short-term stroke outcome. Future studies will reveal whether we will observe an increasing trend in the use of rt-PA and endovascular thrombectomy and whether it will result in improved functional outcome for VEP.