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BACKGROUND: With the expanding eligibility for endovascular therapy (EVT) of patients presenting in the late window (6-24 hours after last known well), we aimed to derive a score to predict favorable outcomes associated with EVT versus best medical management. METHODS AND RESULTS: A multinational observational cohort of patients from the CLEAR (Computed Tomography for Late Endovascular Reperfusion) study with proximal intracranial occlusion (2014-2022) was queried (n=58 sites). Logistic regression analyses were used to derive a 9-point score for predicting good functional outcome (modified Rankin Scale score 0-2 or return to premorbid modified Rankin Scale score) at 90 days, with sensitivity analyses for prespecified subgroups conducted using bootstrapped random forest regressions. Secondary outcomes included 90-day functional independence (modified Rankin Scale score 0-2), poor outcome (modified Rankin Scale score 5-6), and 90-day survival. The score was externally validated with a single-center cohort (2014-2023). Of the 3231 included patients (n=2499 EVT), a 9-point score included age, early computed tomography ischemic changes, and stroke severity, with higher points indicating a higher probability of a good functional outcome. The areas under the curve for the primary outcome among EVT and best medical management subgroups were 0.72 (95% CI, 0.70-0.74) and 0.87 (95% CI, 0.84-0.90), respectively, with similar performance in the external validation cohort (area under the curve, 0.71 [95% CI, 0.66-0.76]). There was a significant interaction between the score and EVT for good functional outcome, functional independence, and poor outcome (all Pinteraction<0.001), with greater benefit favoring patients with lower and midrange scores. CONCLUSIONS: This score is a pragmatic tool that can estimate the probability of a good outcome with EVT in the late window. REGISTRATION: URL: https://www.Clinicaltrials.gov; Unique identifier: NCT04096248.
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Procedimientos Endovasculares , Trombectomía , Humanos , Masculino , Femenino , Procedimientos Endovasculares/métodos , Anciano , Trombectomía/métodos , Persona de Mediana Edad , Resultado del Tratamiento , Factores de Tiempo , Accidente Cerebrovascular Isquémico/fisiopatología , Accidente Cerebrovascular Isquémico/terapia , Recuperación de la Función , Estado Funcional , Valor Predictivo de las Pruebas , Medición de Riesgo/métodos , Tiempo de Tratamiento , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND AND PURPOSE: Posterior cerebral artery occlusion (PCAo) can cause long-term disability, yet randomized controlled trials to guide optimal reperfusion strategy are lacking. We compared the outcomes of PCAo patients treated with endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) to patients treated with IVT alone. METHODS: From the multicenter retrospective Posterior cerebraL ArTery Occlusion (PLATO) registry, we included patients with isolated PCAo treated with reperfusion therapy within 24 hours of onset between January 2015 and August 2022. The primary outcome was the distribution of the modified Rankin Scale (mRS) at 3 months. Other outcomes comprised 3-month excellent (mRS 0-1) and independent outcome (mRS 0-2), early neurological improvement (ENI), mortality, and symptomatic intracranial hemorrhage (sICH). The treatments were compared using inverse probability weighted regression adjustment. RESULTS: Among 724 patients, 400 received EVT+/-IVT and 324 IVT alone (median age 74 years, 57.7% men). The median National Institutes of Health Stroke Scale score on admission was 7, and the occluded segment was P1 (43.9%), P2 (48.3%), P3-P4 (6.1%), bilateral (1.0%), or fetal posterior cerebral artery (0.7%). Compared to IVT alone, EVT+/-IVT was not associated with improved functional outcome (adjusted common odds ratio [OR] 1.07, 95% confidence interval [CI] 0.79-1.43). EVT increased the odds for ENI (adjusted OR [aOR] 1.49, 95% CI 1.05-2.12), sICH (aOR 2.87, 95% CI 1.23-6.72), and mortality (aOR 1.77, 95% CI 1.07-2.95). CONCLUSION: Despite higher odds for early improvement, EVT+/-IVT did not affect functional outcome compared to IVT alone after PCAo. This may be driven by the increased risk of sICH and mortality after EVT.
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BACKGROUND AND PURPOSE: We compared the outcomes of endovascular therapy (EVT) in an extended time window in patients with large-vessel occlusion (LVO) between patients with and without pre-stroke disability. METHODS: In this prespecified analysis of the multinational CT for Late Endovascular Reperfusion study (66 participating sites, 10 countries between 2014 and 2022), we analyzed data from patients with acute ischemic stroke with a pre-stroke modified Rankin Scale (mRS) score of 0-4 and LVO who underwent EVT 6-24 hours from the time last seen well. The primary outcome was the composite of functional independence (FI; mRS score 0-2) or return to the pre-stroke mRS score (return of Rankin, RoR) at 90 days. Outcomes were compared between patients with pre-stroke disability (pre-stroke mRS score 2-4) and those without (mRS score 0-1). RESULTS: A total of 2,231 patients (median age, 72 years; median National Institutes of Health Stroke Scale score, 16) were included in the present analysis. Of these, 564 (25%) had pre-stroke disability. The primary outcome (FI or RoR) was observed in 30.7% of patients with pre-stroke disability (FI, 16.5%; RoR, 30.7%) compared to 44.1% of patients without (FI, 44.1%; RoR, 13.0%) (P<0.001). In multivariable logistic regression analysis with inverse probability of treatment weighting, pre-stroke disability was not associated with significantly lower odds of achieving FI or RoR (adjusted odds ratio 0.73, 95% confidence interval 0.43-1.25). Symptomatic intracranial hemorrhage occurred in 6.3% of both groups (P=0.995). CONCLUSION: A considerable proportion of patients with late-presenting LVO and pre-stroke disability regained pre-stroke mRS scores after EVT. EVT may be appropriate for patients with pre-stroke disability presenting in the extended time window.
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BACKGROUND: The optimal anesthetic strategy for endovascular therapy (EVT) in acute ischemic stroke is still under debate. The aim of this study was to compare the clinical outcomes of patients with isolated posterior cerebral artery (PCA) occlusion stroke undergoing EVT by anesthesia modality with conscious sedation (non-GA) versus general anesthesia (GA). METHODS: Patients from the Posterior CerebraL Artery Occlusion (PLATO) study were analyzed with regard to anesthetic strategy. GA was compared with non-GA using multivariable logistic regression and inverse probability of weighting treatment (IPTW) methods. The primary endpoint was the 90-day distribution of the modified Rankin Scale (mRS) score. Secondary outcomes included functional independence or return to Rankin at day 90, and successful reperfusion, defined as expanded Thrombolysis in Cerebral Infarction (eTICI) 2b to 3. Safety endpoints were symptomatic intracranial hemorrhage and mortality. RESULTS: Among 376 patients with isolated PCA occlusion stroke treated with EVT, 183 (49%) had GA. The treatment groups were comparable, although the GA group contained more patients with severe stroke and lower posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS). On IPTW analysis, there was no difference between groups with regard to ordinal mRS shift analysis (common OR 0.89, 95% CI 0.53 to 1.51, P=0.67) or functional independence (OR 0.84, 95% CI 0.50 to 1.39, P=0.49). There were greater odds for successful reperfusion with GA (OR 1.70, 95% CI 1.17 to 2.47, P=0.01). Safety outcomes were comparable between groups. CONCLUSION: In patients with isolated PCA occlusion undergoing EVT, patients treated with GA had higher reperfusion rates compared with non-GA. Both GA and non-GA strategies were safe and functional outcomes were similar.
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INTRODUCTION: The benefit of endovascular therapy (EVT) among stroke patients with large ischemic core (ASPECTS 0-5) in the extended time window outside of trial settings remains unclear. We analyzed the effect of EVT among these stroke patients in real-world settings. PATIENTS AND METHODS: The CT for Late Endovascular Reperfusion (CLEAR) study recruited patients from 66 centers in 10 countries between 01/2014 and 05/2022. The extended time-window was defined as 6-24 h from last-seen-well to treatment. The primary outcome was shift of the 3-month modified Rankin scale (mRS) score. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and mortality. Outcomes were analyzed with ordinal and logistic regressions. RESULTS: Among 5098 screened patients, 2451 were included in the analysis (median age 73, 55% women). Of patients with ASPECTS 0-5 (n = 310), receiving EVT (n = 209/310) was associated with lower 3-month mRS when compared to medical management (median 4 IQR 3-6 vs 6 IQR 4-6; aOR 0.4, 95% CI 0.2-0.7). Patients undergoing EVT had higher sICH (11.2% vs 4.0%; aOR 4.1, 95% CI 1.2-18.8) and lower mortality (31.6% vs 58.4%, aOR 0.4; 95% CI 0.2-0.9) compared to medically managed patients. The relative benefit of EVT was comparable between patients with ASPECTS 0 and 5 and 6-10 in the extended time window (interaction aOR 0.9; 95% CI 0.5-1.7). CONCLUSION: In the extended time window, patients with ASPECTS 0-5 may have preserved relative treatment benefit of EVT compared to patients with ASPECTS 6-10. These findings are in line with recent trials showing benefit of EVT among real-world patients with large ischemic core in the extended time window. TRIAL REGISTRATION NUMBER: clinicaltrials.gov; Unique identifier: NCT04096248.
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BACKGROUND: The aim of this study was to contribute to the theoretical development within the field of labour market effects on mental health during life by integrating Bronfenbrenner's ecological model with mainly earlier theoretical work on life-course theory. METHODS: An integrative review was performed of all 52 publications about labour market conditions in relation to mental health from the longitudinal Northern Swedish Cohort study. Inductive and deductive qualitative content analysis were performed in relation to Bronfenbrenner's ecological framework combined with life-course theories. RESULTS: The following nine themes were identified: 1. Macroeconomic recession impairs mental health among young people. 2. The mental health effects on individuals of youth unemployment seem rather insensitive to recession. 3. Small but consistent negative effect of neighbourhood unemployment and other work-related disadvantaged on individuals' mental health over life. 4. Youth unemployment becomes embodied as scars of mental ill-health over life. 5. Weak labour market attachment impairs mental health over life. 6. Bidirectional relations between health and weak labour market attachment over life. 7. Macrolevel structures are of importance for how labour market position cause poor health. 8. Unequal gender relations at work impacts negatively on mental health. 9. The agency to improve health over life in dyadic relations. Unemployment in society permeates from the macrolevel into the exolevel, defined by Bronfenbrenner as for example the labour market of parents or partners or the neighbourhood into the settings closest to the individual (the micro- and mesolevel) and affects the relations between the work, family, and leisure spheres of the individual. Neighbourhood unemployment leads to poor health among those who live there, independent of their employment status. Individuals' exposure to unemployment and temporary employment leads to poorer mental health over the life-course. Temporal dimensions were identified and combined with Bronfenbrenner levels into a contextual life-course model CONCLUSION: Combining the ecosocial theory with life-course theories provides a framework for understanding the embodiment of work-related mental health over life. The labour market conditions surrounding the individual are of crucial importance for the embodiment of mental health over life, at the same time as individual agency can be health promoting. Mental health can be improved by societal efforts in regulations of the labour market.
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Salud Mental , Desempleo , Humanos , Suecia/epidemiología , Salud Mental/estadística & datos numéricos , Femenino , Masculino , Desempleo/psicología , Desempleo/estadística & datos numéricos , Adulto , Empleo/psicología , Empleo/estadística & datos numéricos , Adolescente , Estudios de Cohortes , Modelos Teóricos , Adulto Joven , Estudios Longitudinales , Recesión Económica , Trastornos Mentales/epidemiología , Trastornos Mentales/psicologíaRESUMEN
BACKGROUND: Acute ischemic stroke with isolated posterior cerebral artery occlusion (iPCAO) lacks management evidence from randomized trials. We aimed to evaluate whether the association between endovascular treatment (EVT) and outcomes in iPCAO acute ischemic stroke is modified by initial stroke severity (baseline National Institutes of Health Stroke Scale [NIHSS]) and arterial occlusion site. METHODS: Based on the multicenter, retrospective, case-control study of consecutive iPCAO acute ischemic stroke patients (PLATO study [Posterior Cerebral Artery Occlusion Stroke]), we assessed the heterogeneity of EVT outcomes compared with medical management (MM) for iPCAO, according to baseline NIHSS score (≤6 versus >6) and occlusion site (P1 versus P2), using multivariable regression modeling with interaction terms. The primary outcome was the favorable shift of 3-month modified Rankin Scale (mRS). Secondary outcomes included excellent outcome (mRS score 0-1), functional independence (mRS score 0-2), symptomatic intracranial hemorrhage, and mortality. RESULTS: From 1344 patients assessed for eligibility, 1059 were included (median age, 74 years; 43.7% women; 41.3% had intravenous thrombolysis): 364 receiving EVT and 695 receiving MM. Baseline stroke severity did not modify the association of EVT with 3-month mRS distribution (Pinteraction=0.312) but did with functional independence (Pinteraction=0.010), with a similar trend on excellent outcome (Pinteraction=0.069). EVT was associated with more favorable outcomes than MM in patients with baseline NIHSS score >6 (mRS score 0-1, 30.6% versus 17.7%; adjusted odds ratio [aOR], 2.01 [95% CI, 1.22-3.31]; mRS score 0 to 2, 46.1% versus 31.9%; aOR, 1.64 [95% CI, 1.08-2.51]) but not in those with NIHSS score ≤6 (mRS score 0-1, 43.8% versus 46.3%; aOR, 0.90 [95% CI, 0.49-1.64]; mRS score 0-2, 65.3% versus 74.3%; aOR, 0.55 [95% CI, 0.30-1.0]). EVT was associated with more symptomatic intracranial hemorrhage regardless of baseline NIHSS score (Pinteraction=0.467), while the mortality increase was more pronounced in patients with NIHSS score ≤6 (Pinteraction=0.044; NIHSS score ≤6: aOR, 7.95 [95% CI, 3.11-20.28]; NIHSS score >6: aOR, 1.98 [95% CI, 1.08-3.65]). Arterial occlusion site did not modify the association of EVT with outcomes compared with MM. CONCLUSIONS: Baseline clinical stroke severity, rather than the occlusion site, may be an important modifier of the association between EVT and outcomes in iPCAO. Only severely affected patients with iPCAO (NIHSS score >6) had more favorable disability outcomes with EVT than MM, despite increased mortality and symptomatic intracranial hemorrhage.
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Procedimientos Endovasculares , Infarto de la Arteria Cerebral Posterior , Humanos , Femenino , Masculino , Anciano , Procedimientos Endovasculares/métodos , Estudios Retrospectivos , Persona de Mediana Edad , Anciano de 80 o más Años , Infarto de la Arteria Cerebral Posterior/diagnóstico por imagen , Resultado del Tratamiento , Estudios de Casos y Controles , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular Isquémico/terapia , Terapia Trombolítica/métodos , Accidente Cerebrovascular/terapiaRESUMEN
BACKGROUND: Studies comparing bridging intravenous thrombolysis (IVT) with direct endovascular therapy (EVT) in patients with acute ischemic stroke who present late are limited. We aimed to compare the clinical outcomes and safety of bridging IVT in patients with acute ischemic stroke due to anterior circulation large vessel occlusion who underwent EVT 6 to 24 hours after time last known well. METHODS: We enrolled patients with anterior circulation large vessel occlusion stroke and a National Institutes of Health Stroke Scale score of ≥6 from 20 centers across 10 countries in the multicenter retrospective CLEAR study (CT for Late Endovascular Reperfusion) between January 2014 and May 2022. We used inverse probability of treatment weighting modeling adjusted for clinical and imaging confounders to compare functional outcomes, reperfusion success, symptomatic intracranial hemorrhage, and mortality between EVT patients with and without prior IVT. RESULTS: Of 5098 patients screened for eligibility, we included 2749 patients, of whom 549 received bridging IVT before EVT. The timing of IVT was not recorded. Witnessed stroke onset and transfer rates were higher in the bridging IVT group (25% versus 12% and 77% versus 55%, respectively, P value for both <0.0001), and time intervals between stroke onset and treatment were shorter (time last known well-start of EVT median 560 minutes [interquartile range, 432-791] versus 724 minutes [interquartile range, 544-912]; P<0.0001). After adjustment for confounders, there was no difference in functional outcome at 3 months (adjusted common odds ratio for modified Rankin Scale shift, 1.03 [95% CI, 0.89-1.19]; P=0.72) or successful reperfusion (adjusted odds ratio, 1.19 [95% CI, 0.81-1.75]; P=0.39). There were no safety concerns associated with bridging IVT versus direct EVT (symptomatic intracranial hemorrhage: adjusted odds ratio, 0.75 [95% CI, 0.38-1.48]; P=0.40; mortality: adjusted odds ratio, 1.14 [95% CI, 0.89-1.46]; P=0.31). Results were unchanged when the analysis was limited to patients who received IVT >6 hours after last known well. CONCLUSIONS: In patients with an anterior circulation large vessel occlusion stroke who underwent EVT 6 to 24 hours from last known well, bridging IVT was not associated with a difference in outcomes compared with direct EVT. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096248.
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Procedimientos Endovasculares , Accidente Cerebrovascular Isquémico , Terapia Trombolítica , Humanos , Masculino , Femenino , Anciano , Accidente Cerebrovascular Isquémico/terapia , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Accidente Cerebrovascular Isquémico/cirugía , Procedimientos Endovasculares/métodos , Persona de Mediana Edad , Terapia Trombolítica/métodos , Resultado del Tratamiento , Estudios Retrospectivos , Anciano de 80 o más Años , Fibrinolíticos/uso terapéutico , Fibrinolíticos/administración & dosificación , Tiempo de Tratamiento , Isquemia Encefálica/tratamiento farmacológico , Isquemia Encefálica/terapiaRESUMEN
BACKGROUND AND OBJECTIVES: There is uncertainty whether patients with large vessel occlusion (LVO) presenting in the late 6-hour to 24-hour time window can be selected for endovascular therapy (EVT) by noncontrast CT (NCCT) and CT angiography (CTA) for LVO detection. We evaluated the clinical outcomes of patients selected for EVT by NCCT compared with those medically managed in the extended time window. METHODS: This multinational cohort study was conducted at 66 sites across 10 countries. Consecutive patients with proximal anterior LVO stroke selected for EVT by NCCT or medically managed and presenting within 6-24 hours of time last seen well (TSLW) from January 2014 to May 2022 were included. The primary end point was the 90-day ordinal shift in the modified Rankin Scale (mRS) score. Inverse probability treatment weighting (IPTW) and multivariable methods were used. RESULTS: Of 5,098 patients screened, 839 patients were included, with a median (interquartile range) age of 75 (64-83) years; 455 (54.2%) were women. There were 616 patients selected to undergo EVT by NCCT (73.4%) and 223 (26.6%) who were medically managed. In IPTW analyses, there was a more favorable 90-day ordinal mRS shift in patients selected by NCCT to EVT vs those who were medically managed (odds ratio [OR] 1.99, 95% CI 1.53-2.59; p < 0.001). There were higher rates of 90-day functional independence (mRS 0-2) in the EVT group (40.1% vs 18.4%, OR 3.31, 95% CI 2.11-5.20; p < 0.001). sICH was nonsignificantly higher in the EVT group (8.5% vs 1.4%, OR 3.77, 95% CI 0.72-19.7, p = 0.12). Mortality at 90 days was lower in the EVT vs MM group (23.9% vs 32.3%, OR 0.61, 95% CI 0.45-0.83, p = 0.002). DISCUSSION: In patients with proximal anterior LVO in the extended time window, there was a lower rate of disability and mortality in patients selected with NCCT and CTA to EVT compared with those who were medically managed. These findings support the use of NCCT as a simpler and more inclusive approach to patient selection in the extended window. TRIAL REGISTRATION INFORMATION: This study was registered at ClinicalTrials.gov under NCT04096248. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with proximal anterior circulation occlusion presenting with ischemic stroke from 6 to 24 hours, compared with medical management, those undergoing thrombectomy based on NCCT have reduced disability and mortality at 90 days.
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Procedimientos Endovasculares , Trombectomía , Humanos , Femenino , Anciano , Masculino , Trombectomía/métodos , Anciano de 80 o más Años , Persona de Mediana Edad , Procedimientos Endovasculares/métodos , Angiografía por Tomografía Computarizada , Tomografía Computarizada por Rayos X , Estudios de Cohortes , Tiempo de Tratamiento , Resultado del Tratamiento , Angiografía CerebralRESUMEN
Introduction: Drawing upon the framework of life course epidemiology, this study aligns with research on the mental health consequences of significant social transitions during early adulthood. The focus is on the variation in initial labour market attachment and the development of depressiveness, assuming that a firm attachment is associated with decreasing depressiveness. Methods: The baseline investigation of the studied cohort (n = 1,001) took place during their final year of compulsory schooling at age 16. Follow-up surveys were conducted at ages 18, 21, 30, and 43. Depressiveness was measured with a five-item score. Multiple trajectory analysis, incorporating five labour market statuses observed over seven half-year periods from ages 18 to 21, was employed to categorize the cohort into six distinct groups. Among these, 'All-time education,' 'From education to employment,' 'Education and employment,' and 'From employment to education' were considered to demonstrate firm labour market attachment. Meanwhile, 'Active labour market policy' and 'Unemployment' represented less firm attachment. Results: The trajectory of depressive symptoms among the total cohort from age 16 to age 43 exhibited a 'broken stick' pattern, reaching its lowest point at age 21. This pattern was evident in all groups classified as having a firm attachment. A substantial decrease in depressiveness was also observed in the relatively weakly attached 'Active labour market policy' group, whereas no 'broken stick' pattern emerged in the 'Unemployment' group. The disparities in the levels of depressiveness observed at age 21 remained relatively stable across the measurements at ages 30 and 43. Discussion: The results were as expected, except for the observed improvement in mental health within the 'Active labour market policy' group. Supported labour market attachment during emerging adulthood can enhance mental well-being similarly to regular mainstream attachment. In terms of policy recommendations, the consistently high levels of depressiveness within the 'Unemployment' group underscore the importance of reducing long-term and repeated unemployment in young age. The findings regarding the 'Active labour market policy' provide evidence of the intervention's benefits. While the primary goal of these measures is to create jobs for the unemployed, they also include elements that contribute to participants' mental health.
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Depresión , Empleo , Humanos , Suecia , Femenino , Adulto , Empleo/estadística & datos numéricos , Masculino , Adolescente , Depresión/epidemiología , Adulto Joven , Estudios de CohortesRESUMEN
BACKGROUND AND OBJECTIVES: Recanalization is considered a prerequisite for favorable outcome in basilar artery occlusion (BAO). Intravenous thrombolysis (IVT) has been successfully used for eligible patients with BAO well beyond the 4.5-hour time window but has been largely underrepresented in the best medical management arms in recent randomized controlled trials of recanalization therapy in BAO. We aimed to analyze the outcomes of patients with BAO treated with IVT only and to compare IVT with endovascular thrombectomy (EVT). METHODS: This observational single-center, retrospective cohort study included consecutive patients with BAO treated with IVT and/or EVT up to 48 hours of symptom onset during 1995-2022. The primary outcome was favorable functional outcome (modified Rankin Scale 0-3) at 3 months collected by a stroke physician by phone. In the first part, we described the outcomes and factors associated with functional outcome in the IVT-only cohort during 1995-2022. In the second part, we used doubly robust inverse probability-weighted regression adjustment models to compare functional outcome of patients treated with IVT vs EVT+/-IVT during 2010-2022. RESULTS: In the whole cohort of 376 patients with acute BAO treated with recanalization therapy, 245 (65.2%) received only IVT. In the IVT-only cohort, most patients had moderate-to-severe clinical presentation (median NIH Stroke Scale 18) but no extensive early ischemic changes in the posterior circulation on admission. Half of them had onset-to-treatment time over 6 hours. 46.5% of the IVT-treated patients achieved 3-month favorable functional outcome, whereas mortality was 35.9%. sICH occurred in 11.1%. In a multivariable analysis, younger age, milder symptom severity, and less baseline ischemic changes predicted favorable functional outcome. In the 2010-2022 cohort, when compared with patients treated with EVT+/-IVT (n = 121), the IVT-only cohort (n = 122) had higher odds for favorable functional outcome (IVT 58.2% vs EVT 43.0% (aOR 2.82 [95% CI 1.31-6.05]). DISCUSSION: IVT alone produced outcomes comparable with those in recent trials of endovascular BAO recanalization. Furthermore, in head-to-head comparison in our cohort, the IVT-only approach was more often associated with favorable outcome than EVT+/-IVT. Thus, it should not be overlooked as the first-line recanalization therapy in acute BAO, even in longer time windows. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that tPA is as effective as thrombectomy for basilar artery thrombosis.
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Arteriopatías Oclusivas , Procedimientos Endovasculares , Accidente Cerebrovascular , Humanos , Arteria Basilar , Estudios Retrospectivos , Resultado del Tratamiento , Trombectomía/efectos adversos , Terapia Trombolítica/efectos adversos , Arteriopatías Oclusivas/terapia , Accidente Cerebrovascular/terapiaRESUMEN
BACKGROUND: The association between sex and outcome after endovascular thrombectomy of acute ischemic stroke is unclear. The aim of this study was to compare the clinical and safety outcomes between men and women treated with endovascular thrombectomy in the late 6-to-24-hour window period. METHODS: This multicenter, retrospective observational cohort study included consecutive patients who underwent endovascular thrombectomy of anterior circulation stroke in the late window from 66 clinical sites in 10 countries from January 2014 to May 2022. The primary outcome was the 90-day ordinal modified Rankin Scale score. Secondary outcomes included 90-day functional independence (FI), return of Rankin (RoR) to prestroke baseline, FI or RoR, symptomatic intracranial hemorrhage, and mortality. Multivariable and inverse probability of treatment weighting methods were used. We explored the interaction of sex with baseline characteristics on the outcomes ordinal modified Rankin Scale and FI or RoR. RESULTS: Of 1932 patients, 1055 were women and 877 were men. Women were older (77 versus 69 years), had higher rates of atrial fibrillation, hypertension, and greater prestroke disability, but there was no difference in baseline National Institutes of Health Stroke Scale score. Inverse probability of treatment weighting analysis showed no difference between women and men in ordinal modified Rankin Scale (odds ratio, 0.98 [95% CI, 0.79-1.21]), FI or RoR (odds ratio, 0.98 [95% CI, 0.78-1.22]), severe disability or mortality (odds ratio, 0.99 [95% CI, 0.80-1.23]). The multivariable analysis of the above end points was concordant. There were no interactions between baseline characteristics and sex on the outcomes of ordinal modified Rankin Scale and FI or RoR. CONCLUSIONS: In late presenting patients with anterior circulation stroke treated with endovascular thrombectomy in the 6 to 24-hour window, there was no difference in clinical or safety outcomes between men and women.
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Fibrilación Atrial , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Estados Unidos , Humanos , Femenino , Masculino , Caracteres Sexuales , Estudios Retrospectivos , Accidente Cerebrovascular/cirugíaRESUMEN
BACKGROUND: This study, conducted on a Swedish population cohort, explores how internalized (depressive and functional somatic) and externalized (smoking, drinking, truancy, vandalism, delinquency) mental health symptoms, as well as close interpersonal relations (family climate and school connectedness) reported during adolescence, influence the work-life course up to late midlife. METHODS: We examined repeated measurements of labour market status from age 16 to 56 using sequence analyses. We identified five different labour market attachment (LMA16-56) trajectories, namely 'strong,' 'early intermediate,' 'early weak,' 'late weak,' and 'constantly weak.' Multinomial logistic regressions were employed to relate each of the nine determinants to the identified trajectories. RESULTS: When compared to the risk of 'strong' LMA16-56, adversity in all conditions, except for vandalism, entailed a higher risk of the 'constantly weak' trajectory. Moreover, all conditions, except for functional somatic symptoms, entailed a higher risk of the 'late weak' LMA16-56. The risk of the 'early intermediate' LMA16-56 was non-significant across all the conditions. CONCLUSIONS: This study contributes to existing knowledge through its novel exploration of labour market attachment and the revelation of the significance of proximal interpersonal relationships in attachment outcomes. Additionally, the study reaffirms the importance of externalizing behaviour, while suggesting that internalized symptoms in adolescence might have a less influential, though not negligible, role. These results underscore the importance of addressing acting out behaviour and nurturing human relationships during compulsory basic education, when the entire age group is still within reach. This approach aims not only to reduce frictions in the school-to-work transition but also to prevent midlife labour market attachment problems that may arise with delayed intervention.
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Trastornos Mentales , Adolescente , Humanos , Adulto Joven , Adulto , Persona de Mediana Edad , Suecia/epidemiología , Trastornos Mentales/epidemiología , Salud Mental , Ocupaciones , EscolaridadRESUMEN
AIM: The aim of the paper is to analyse if alcohol consumption could explain the scarring effect of youth unemployment on later depressive symptoms. METHODS: The analyses are based on the 24-year follow-up of school leavers in a municipality in Northern Sweden (the Northern Swedish Cohort). Four-way decomposition analyses were performed to analyse if alcohol use at age 30 years could mediate and/or moderate the effect of youth unemployment (ages 18/21 years) on depressive symptoms in later adulthood (age 43 years). RESULTS: Excessive alcohol use at early adulthood (age 30 years) mediates 18% of the scarring effect of youth unemployment on depressive symptoms in later adulthood. The scarring effect was seen among both those with and without excessive alcohol use. CONCLUSIONS: Youth unemployment leads to poor mental health later in life and part of these relations are explained by excessive alcohol consumption in early adulthood. Policy interventions should target the prevention of youth unemployment for reaching a lower alcohol consumption and better mental health.
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INTRODUCTION: Present-day computer tomography (CT) scanners have excellent spatial resolution and signal-to-noise ratio and are instrumental detecting early ischemic changes (EIC) in brain. We assessed the temporal changes of EIC based on the recanalization status after thrombectomy. PATIENTS AND METHODS: The cohort comprises consecutive patients with acute ischemic stroke in anterior circulation treated with thrombectomy in tertiary referral hospital. All baseline and follow-up scans were screened for any ischemic changes and further classified using Alberta Stroke Program Early CT Score (ASPECTS). Generalized linear mixed models were used to analyze the impact of recanalization status using modified Thrombolysis in Cerebral Infarction (mTICI) on temporal evolution of ischemic changes. RESULTS: We included 614 patients with ICA, M1, or M2 occlusions. Median ASPECTS score was 9 (IQR 7-10) at baseline and 7 (5-8) at approximately 24 h. mTICI 3 was achieved in 207 (33.8%), 2B 241 (39.3%), 2A in 77 (12.6%), and 0-1 in 88 (14.3%) patients. Compared to patients with mTICI 3, those with mTICI 0-1 and 2A had less favorable temporal changes of ASPECTS (p < 0.001). Effect of recanalization was noted in the cortical regions of ICA/M1 patients, but not in their deep structures or patients with M2 occlusions. All ischemic changes detected at baseline were also present at all follow-up images, regardless of the recanalization status. CONCLUSIONS: Temporal evolution of the ischemic changes and ASPECTS are related to the success of the recanalization therapy in cortical regions of ICA/M1 patients, but not in their deep brain structures or M2 patients. In none of the patients did EIC revert in any brain region after successful recanalization.
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BACKGROUND: The optimal management of patients with isolated posterior cerebral artery occlusion is uncertain. We compared clinical outcomes for endovascular therapy (EVT) versus medical management (MM) in patients with isolated posterior cerebral artery occlusion. METHODS: This multinational case-control study conducted at 27 sites in Europe and North America included consecutive patients with isolated posterior cerebral artery occlusion presenting within 24 hours of time last well from January 2015 to August 2022. Patients treated with EVT or MM were compared with multivariable logistic regression and inverse probability of treatment weighting. The coprimary outcomes were the 90-day modified Rankin Scale ordinal shift and ≥2-point decrease in the National Institutes of Health Stroke Scale. RESULTS: Of 1023 patients, 589 (57.6%) were male with median (interquartile range) age of 74 (64-82) years. The median (interquartile range) National Institutes of Health Stroke Scale was 6 (3-10). The occlusion segments were P1 (41.2%), P2 (49.2%), and P3 (7.1%). Overall, intravenous thrombolysis was administered in 43% and EVT in 37%. There was no difference between the EVT and MM groups in the 90-day modified Rankin Scale shift (aOR, 1.13 [95% CI, 0.85-1.50]; P=0.41). There were higher odds of a decrease in the National Institutes of Health Stroke Scale by ≥2 points with EVT (aOR, 1.84 [95% CI, 1.35-2.52]; P=0.0001). Compared with MM, EVT was associated with a higher likelihood of excellent outcome (aOR, 1.50 [95% CI, 1.07-2.09]; P=0.018), complete vision recovery, and similar rates of functional independence (modified Rankin Scale score, 0-2), despite a higher rate of SICH and mortality (symptomatic intracranial hemorrhage, 6.2% versus 1.7%; P=0.0001; mortality, 10.1% versus 5.0%; P=0.002). CONCLUSIONS: In patients with isolated posterior cerebral artery occlusion, EVT was associated with similar odds of disability by ordinal modified Rankin Scale, higher odds of early National Institutes of Health stroke scale improvement, and complete vision recovery compared with MM. There was a higher likelihood of excellent outcome in the EVT group despite a higher rate of symptomatic intracranial hemorrhage and mortality. Continued enrollment into ongoing distal vessel occlusion randomized trials is warranted.
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Isquemia Encefálica , Procedimientos Endovasculares , Accidente Cerebrovascular , Humanos , Masculino , Anciano , Anciano de 80 o más Años , Femenino , Isquemia Encefálica/terapia , Trombectomía , Estudios de Casos y Controles , Arteria Cerebral Posterior/diagnóstico por imagen , Procedimientos Endovasculares/efectos adversos , Hemorragias Intracraneales/etiología , Resultado del TratamientoRESUMEN
OBJECTIVES: White matter hypodensities (WMH), a surrogate of small vessel disease, associate with cognitive decline and stroke risk. The impact of WMH on functional outcome after intracerebral hemorrhage (ICH) has differed between studies. We aimed to examine factors associated with the severity of WMH in ICH, and whether there is an independent association between the extent of WMH and outcome. MATERIALS AND METHODS: This was a prospective study of consented patients with non-traumatic primary ICH, admitted to the Helsinki University Hospital between May 2014 and December 2018. To evaluate the extent of the WMH, modified van Swieten score of the side contralateral to the ICH was obtained. Patients were grouped into 3 categories of the scores. We performed univariate and multivariable analyses to find out factors associated with the severity of WMH, and whether WMH associate with functional outcome and mortality up to 12 months, adjusted for the known major outcome predictors. RESULTS: In our cohort of 417 ICH patients, WMH severity associated with older age, female sex, admission National Institutes of Health Stroke Scale (NIHSS) points, and signs of previous ischemic stroke on CT. We found an independent association between WMH severity and poor functional outcome at 3 months (OR 1.72, 95% CI 1.27-2.33), and 1 year (OR 2.16, 95% CI 1.57-2.95), and mortality at 1 year (OR 1.91, 95% CI 1.29-2.85). CONCLUSIONS: In our ICH patients, vascular comorbidities and older age associated with the presence of WMH, which, in turn, strongly associated with poor functional outcome.
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Accidente Cerebrovascular , Sustancia Blanca , Humanos , Femenino , Sustancia Blanca/diagnóstico por imagen , Estudios Prospectivos , Hemorragia Cerebral/diagnóstico por imagenRESUMEN
BACKGROUND: The prevalence of mental disorders is increased among people of low socioeconomic status or educational level, but it remains unclear whether their access to treatment matches their increased need. AIMS: Our objective was to examine whether educational level as an indicator of socioeconomic status is associated with use of mental health services, psychotropic medication and psychotherapy in Finland. METHOD: Cross-sectional data from a follow-up survey of a longitudinal, population-based cohort study were used to form a sample of 3,053 men and women aged 24 to 68 with a current or previous physician diagnosed mental disorder. The prevalence of mental disorders, mental health service use and educational level were assessed with self-report questionnaire. Educational level was determined by the highest educational attainment and grouped into three levels: high, intermediate and low. The associations between educational level and mental health service -related outcomes were assessed with binary logistic regression. Covariates in the fully adjusted model were age, gender and number of somatic diseases. RESULTS: Compared to high educational level, low educational level was associated with higher odds of using antidepressants (OR 1.35, 95% CI [1.09, 1.66]), hypnotics (OR 1.33, 95% CI [1.07, 1.66]) and sedatives (OR 2.17, 95% CI [1.69, 2.78]), and lower odds of using mental health services (OR 0.80, 95% CI [0.65, 0.98]). No associations were found between educational level and use of psychotherapy. CONCLUSIONS: The results do not suggest a general socioeconomic status related mismatch. A pharmacological emphasis was observed in the treatment of low educational background participants, whereas overall mental health service use was emphasized among high educational background participants.
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Trastornos Mentales , Servicios de Salud Mental , Masculino , Adulto , Humanos , Femenino , Estudios de Cohortes , Estudios Transversales , Psicotrópicos/uso terapéutico , Trastornos Mentales/psicología , Escolaridad , Hipnóticos y Sedantes/uso terapéutico , PsicoterapiaRESUMEN
AIMS: Psychotherapy is a widely used treatment for mental disorders, but whether it also improves employment and other labour market outcomes remains inconclusive. This study examined the effectiveness of a nationwide subsidized psychotherapy programme using extensive register-based data. METHODS: The sample consisted of individuals who applied for rehabilitative psychotherapy in Finland in 2009-2012 (n = 35,083). Prior to 2011, some applications were rejected due to the limited budget that the central government provided for the programme. From 2011, all eligible applicants were granted rehabilitation. We used propensity score matching to create balanced samples of those who received a negative decision in 2009-2010 (n = 2047) and those who were granted rehabilitative psychotherapy in 2011-2012 (n = 12,046) in terms of their sociodemographic background characteristics, prior labour market attachment and health status. RESULTS: We found that compared to the applicants who were not accepted to the programme, the granted applicants with similar background characteristics had, on average, a six-percentage-point higher employment rate, 2100 higher annual earnings and a six-percentage-point lower probability of becoming a disability benefit recipient five years after their first application. Further sensitivity analyses confirmed that these results were not biased, for example, by differences in macroeconomic conditions during the follow-up. CONCLUSIONS: Quasi-experimental research design showed that rehabilitative psychotherapy was significantly associated with better labour market outcomes. Although several relevant background factors were included in the matching analysis, it is possible that some unobserved factors explain both access to psychotherapy and subsequent labour market outcomes.
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Personas con Discapacidad , Trastornos Mentales , Humanos , Empleo , Ocupaciones , Personas con Discapacidad/rehabilitación , PsicoterapiaRESUMEN
OBJECTIVES: Data concerning the results of endovascular thrombectomy (EVT) in old patients is still limited. We aimed to investigate the outcomes in thrombectomy-treated ischemic stroke patients aged ≥ 80 years, focusing on frailty as a contributing factor. PATIENTS AND METHODS: We performed a single-centre retrospective cohort study with 159 consecutive patients aged ≥ 80 years and treated with EVT for acute ischemic stroke between January 1st 2016 and December 31st 2019. Pre-admission frailty was assessed with the Clinical Frailty Scale (CFS). Patients with CFS ≥ 5 were defined as frail. The main outcome was very poor outcome defined as mRS 4-6 at three months after EVT. Secondary outcomes were recanalization status, symptomatic intracerebral haemorrhage (sICH), and one-year survival. Finally, we recorded if the patient returned home within 12 months. RESULTS: Very poor outcome was observed in 57.9% of all patients (52.4% in non-frail and 79.4% in frail patients). Rates of recanalization and sICH were comparable in frail and non-frail patients. Of all patients, 46.5% were able to live at home within 1 year after stroke. One-year survival was 59.1% (65.6% in non-frail and 35.3% in frail patients). In logistic regression analysis higher admission NIHSS, not performing thrombolysis, lack of recanalization and higher frailty status were all independently associated with very poor three-month outcome. Factors associated with one-year mortality were male gender, not performing thrombolysis, sICH, and higher frailty status. CONCLUSION: Almost 60% of studied patients had very poor outcome. Frailty significantly increases the likelihood of very poor outcome and death after EVT-treated stroke.