24-hour ambulatory blood pressure and cryptogenic ischemic stroke in young adults.

BACKGROUND: In young patients, up to 40% of ischemic strokes remain cryptogenic despite modern-day diagnostic work-up. There are limited data on blood pressure (BP) behavior in these patients. Thus, we aimed to compare ambulatory blood pressure (ABP) profiles between young patients with a recent cryptogenic ischemic stroke (CIS) and stroke-free controls. PATIENTS AND METHODS: In this substudy of the international multicenter case-control study SECRETO (NCT01934725), 24-hour ambulatory blood pressure monitoring (ABPM) was performed in consecutive 18-49-year-old CIS patients and stroke-free controls. The inclusion criteria were met by 132 patients (median age, 41.9 years; 56.1% males) and 106 controls (41.9 years; 56.6% males). We assessed not only 24-hour, daytime, and nighttime ABP but also hypertension phenotypes and nocturnal dipping status. RESULTS: 24-hour and daytime ABP were higher among controls. After adjusting for relevant confounders, a non-dipping pattern of diastolic blood pressure (DBP) was associated with CIS in the entire sample (odds ratio, 3.85; 95% confidence interval, 1.20-12.42), in participants without antihypertensives (4.86; 1.07-22.02), and in participants without a patent foramen ovale (PFO) (7.37; 1.47-36.81). After excluding patients in the first tertile of the delay between the stroke and ABPM, a non-dipping pattern of DBP was not associated with CIS, but a non-dipping pattern of both systolic BP and DBP was (4.85; 1.37-17.10). In participants with a PFO and in those without hypertension by any definition, no associations between non-dipping patterns of BP and CIS emerged. CONCLUSIONS: Non-dipping patterns of BP were associated with CIS in the absence of a PFO but not in the absence of hypertension. This may reflect differing pathophysiology underlying CIS in patients with versus without a PFO. Due to limitations of the study, results regarding absolute ABP levels should be interpreted with caution.Key MessagesNocturnal non-dipping patterns of blood pressure were associated with cryptogenic ischemic stroke except in participants with a patent foramen ovale and in those without hypertension by any definition, which may indicate differing pathophysiology underlying cryptogenic ischemic stroke in patients with and without a patent foramen ovale.It might be reasonable to include ambulatory blood pressure monitoring in the diagnostic work-up for young patients with ischemic stroke to detect not only the absolute ambulatory blood pressure levels but also their blood pressure behavior.

The selection of an optimal transportation strategy in urgent stroke missions: a simulation study.

BACKGROUND: Stroke causes death, disability and increases the use of healthcare resources worldwide. The outcome of intravenous thrombolysis and mechanical endovascular thrombectomy highly depends on the delay from symptom onset to initiation of definitive treatment. The purpose of this study was to compare the various patient transportation strategies to minimize pre-hospital delays. METHODS: Emergency medical services (EMS) mission locations and ambulance response times in Finland with urgent stroke-suspected dispatch codes were collected from Emergency Response Centre (ERC) records between 1 January 2016 and 31 December 2016. Four transport scenarios were simulated for each mission, comparing ground and helicopter transportation to hospital with different treatment capabilities. RESULTS: In 2016, a total of 20,513 urgent stroke-suspected missions occurred in Finland. Of these, we were able to locate and calculate a route to scenario-based hospitals in 98.7% (20,240) of the missions. For ground transport, the estimated median pre-hospital time to a thrombolysis-capable and thrombectomy-capable hospital were 54.5 min (95% confidence interval (CI), 31.7-111.4) and 94.4 min (95% CI, 33.3-195.8), respectively. Should patients be transported on the ground to thrombectomy-capable hospitals only, the pre-hospital time would increase in 11,003 (54.4%) of missions, most of which were in rural areas. With the fastest possible transportation method, the estimated mean transport time to a thrombectomy-capable hospital was 80.84 min (median, 80.80 min; 95% CI, 33.3-143.1). Helicopter transportation was the fastest method in 68.8% (13,921) of missions, and the time saved was greater than 30 min in 27.1% (5475) of missions. In rural areas, helicopter transportation was the fastest option in nearly all missions if dispatched simultaneously with ground ambulance. CONCLUSION: Helicopter transportation may significantly decrease pre-hospital delays for stroke patients, especially in rural areas, but the selection of an optimal transportation method or chain of methods should be determined case-by-case.

Mechanical Thrombectomy of Large Artery Occlusion Is Beneficial in Octogenarians.

AIM: Recent trials have established the benefit of endovascular treatment (EVT) for patients with acute ischemic stroke (AIS) due to large artery occlusion (LAO). However, older patients were often excluded from trials. EVT outcomes were retrospectively compared between octogenarians and younger patients treated for LAO in a tertiary hospital. PATIENTS AND METHODS: A total of 199 consecutive patients with anterior circulation AIS that underwent EVT between 2009 and 2015 in the Kuopio University Hospital were included. Patients were dichotomized into younger (<80 years, N=162) and older (≥80 years, N=37) groups. Baseline, imaging, and procedural characteristics, the 3-month modified Rankin Scale (mRS), and 1-year mortality were assessed. To conduct a number-needed-to-treat (NNT) analysis, data on age-dichotomized control groups from a meta-analysis were acquired. RESULTS: Compared to younger patients, older patients exhibited atrial fibrillation (57% vs. 21%, p<0.01) and coronary artery disease (49% vs. 20%, p<0.01) more frequently and Internal Carotid Artery (ICA) occlusion less frequently (22% vs. 55%, p<0.01). Similar proportions of patients received preprocedural intravenous recombinant tissue-type plasminogen activator (r-tPA; 57% vs. 67%), general anesthesia (35% vs. 41%), and reperfusion (Thrombolysis in Cerebral Infarction scale 2b/3; 76% vs. 75%). Older patients had more complications during hospitalization (41% vs. 24%, p=0.034), higher 3-month mRS values (4.0±2.3 vs. 2.8±1.9, p<0.01), fewer favorable mRS values (mRS≤2: 27% vs. 52%, p<0.01), and higher 3-month (46% vs. 10% p<0.01) and 1-year mortality (49% vs. 11%, p<0.01). The NNT to achieve an additional patient with an independent outcome (mRS≤2) was 12 among older and six among younger patients. CONCLUSION: Despite a poor recovery rate, octogenarians benefitted from EVT for AIS, with a NNT comparable to that of younger patients treated with intravenous r-tPA.