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BACKGROUND: Data from trials investigating the effects and risks of endovascular thrombectomy for the treatment of stroke due to basilar-artery occlusion are limited. METHODS: We conducted a multicenter, prospective, randomized, controlled trial of endovascular thrombectomy for basilar-artery occlusion at 36 centers in China. Patients were assigned, in a 2:1 ratio, within 12 hours after the estimated time of basilar-artery occlusion to receive endovascular thrombectomy or best medical care (control). The primary outcome was good functional status, defined as a score of 0 to 3 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]), at 90 days. Secondary outcomes included a modified Rankin scale score of 0 to 2, distribution across the modified Rankin scale score categories, and quality of life. Safety outcomes included symptomatic intracranial hemorrhage at 24 to 72 hours, 90-day mortality, and procedural complications. RESULTS: Of the 507 patients who underwent screening, 340 were in the intention-to-treat population, with 226 assigned to the thrombectomy group and 114 to the control group. Intravenous thrombolysis was used in 31% of the patients in the thrombectomy group and in 34% of those in the control group. Good functional status at 90 days occurred in 104 patients (46%) in the thrombectomy group and in 26 (23%) in the control group (adjusted rate ratio, 2.06; 95% confidence interval [CI], 1.46 to 2.91, P<0.001). Symptomatic intracranial hemorrhage occurred in 12 patients (5%) in the thrombectomy group and in none in the control group. Results for the secondary clinical and imaging outcomes were generally in the same direction as those for the primary outcome. Mortality at 90 days was 37% in the thrombectomy group and 55% in the control group (adjusted risk ratio, 0.66; 95% CI, 0.52 to 0.82). Procedural complications occurred in 14% of the patients in the thrombectomy group, including one death due to arterial perforation. CONCLUSIONS: In a trial involving Chinese patients with basilar-artery occlusion, approximately one third of whom received intravenous thrombolysis, endovascular thrombectomy within 12 hours after stroke onset led to better functional outcomes at 90 days than best medical care but was associated with procedural complications and intracerebral hemorrhage. (Funded by the Program for Innovative Research Team of the First Affiliated Hospital of USTC and others; ATTENTION ClinicalTrials.gov number, NCT04751708.).
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Arteriopatias Oclusivas , Artéria Basilar , Procedimentos Endovasculares , Acidente Vascular Cerebral , Trombectomia , Humanos , Administração Intravenosa , Arteriopatias Oclusivas/complicações , Arteriopatias Oclusivas/tratamento farmacológico , Arteriopatias Oclusivas/mortalidade , Arteriopatias Oclusivas/cirurgia , Artéria Basilar/efeitos dos fármacos , Artéria Basilar/cirurgia , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/etiologia , Isquemia Encefálica/cirurgia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Fibrinolíticos/uso terapêutico , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/etiologia , Estudos Prospectivos , Qualidade de Vida , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/cirurgia , Trombectomia/efeitos adversos , Trombectomia/métodos , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/métodos , Resultado do Tratamento , Recuperação de Função FisiológicaRESUMO
BACKGROUND: Nontraumatic intracerebral hemorrhage (ICH) is independently associated with a long-term increased risk of major arterial ischemic events. While the relationship between ICH location and ischemic risk has been studied, whether hematoma volume influences this risk is poorly understood. METHODS: We pooled individual patient data from the MISTIE III (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation Phase 3) and the ATACH-2 (Antihypertensive Treatment of Acute Cerebral Hemorrhage-2) trials. The exposure was hematoma volume, treated as a continuous measure in the primary analysis, and dichotomized by the median in the secondary analyses. The outcome was a symptomatic, clinically overt ischemic stroke, adjudicated centrally within each trial. We evaluated the association between hematoma volume and the risk of an ischemic stroke using Cox regression analyses after adjustment for demographics, vascular comorbidities, and ICH characteristics. RESULTS: Of 1470 patients with ICH, the mean age was 61.7 (SD, 12.8) years, and 574 (38.3%) were female. The median hematoma volume was 17.3 mL (interquartile range, 7.2-35.7). During a median follow-up of 107 days (interquartile range, 91-140), a total of 30 ischemic strokes occurred, of which 22 were in patients with a median ICH volume of ≥17.3 mL and a cumulative incidence of 4.6% (95% CI, 3.1-7.1). Among patients with a median ICH volume <17.3 mL, there were 8 ischemic strokes with a cumulative incidence of 3.1% (95% CI, 1.7-6.0). In primary analyses using adjusted Cox regression models, ICH volume was associated with an increased risk of ischemic stroke (hazard ratio, 1.02 per mL increase [95% CI, 1.01-1.04]). In secondary analyses, ICH volume of ≥17.3 mL was associated with an increased risk of ischemic stroke (hazard ratio, 2.5 [95% CI, 1.1-7.2]), compared with those with an ICH volume <17.3 mL. CONCLUSIONS: In a heterogeneous cohort of patients with ICH, initial hematoma volume was associated with a heightened short-term risk of ischemic stroke.
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AVC Isquêmico , Acidente Vascular Cerebral , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Anti-Hipertensivos , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/epidemiologia , Hemorragia Cerebral/complicações , Hematoma/diagnóstico por imagem , Hematoma/epidemiologia , Hematoma/complicações , AVC Isquêmico/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do TratamentoRESUMO
OBJECTIVE: To investigate whether an earlier time to achieving and maintaining systolic blood pressure (SBP) at 120 to 140 mmâ Hg is associated with favorable outcomes in a cohort of patients with acute intracerebral hemorrhage. METHODS: We pooled individual patient data from randomized controlled trials registered in the Blood Pressure in Acute Stroke Collaboration. Time was defined as time form symptom onset plus the time (hour) to first achieve and subsequently maintain SBP at 120 to 140 mmâ Hg over 24 hours. The primary outcome was functional status measured by the modified Rankin Scale at 90 to 180 days. A generalized linear mixed models was used, with adjustment for covariables and trial as a random effect. RESULTS: A total of 5761 patients (mean age, 64.0 [SD, 13.0], 2120 [36.8%] females) were included in analyses. Earlier SBP control was associated with better functional outcomes (modified Rankin Scale score, 3-6; odds ratio, 0.98 [95% CI, 0.97-0.99]) and a significant lower risk of hematoma expansion (0.98, 0.96-1.00). This association was stronger in patients with bigger baseline hematoma volume (>10 mL) compared with those with baseline hematoma volume ≤10 mL (0.006 for interaction). Earlier SBP control was not associated with cardiac or renal adverse events. CONCLUSIONS: Our study confirms a clear time relation between early versus later SBP control (120-140 mmâ Hg) and outcomes in the one-third of patients with intracerebral hemorrhage who attained sustained SBP levels within this range. These data provide further support for the value of early recognition, rapid transport, and prompt initiation of treatment of patients with intracerebral hemorrhage.
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Anti-Hipertensivos , Acidente Vascular Cerebral , Feminino , Humanos , Pessoa de Meia-Idade , Masculino , Pressão Sanguínea/fisiologia , Anti-Hipertensivos/uso terapêutico , Anti-Hipertensivos/farmacologia , Resultado do Tratamento , Hemorragia Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/tratamento farmacológico , Hematoma/tratamento farmacológicoRESUMO
OBJECTIVE: Patients with spontaneous intracerebral hemorrhage (ICH) at the highest risk of hematoma growth are those with the most potential to benefit from anti-expansion treatment. Large clinical trials have not definitively shown a clear benefit of blood pressure (BP) reduction. We aim to determine whether intensive blood pressure reduction could benefit patients with fast bleeding ICH. METHODS: An exploratory analysis of data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) randomized controlled trial was performed. In order to capture not just early bleeding (even if a small amount), but the rate of bleeding (ml/hour), we restricted the study to "Fast bleeding ICH," defined as an ICH volume/onset to computed tomography (CT) time >5 ml/hr. Hematoma growth, as defined as an increase of hematoma volume > 33% between baseline and 24 hours. RESULTS: A total of 940 patients were included (mean age = 62.1 years, 61.5% men), of whom 214 (22.8%) experienced hematoma expansion. Of these, 567 (60.3%) met the definition of "fast bleeding" with baseline ICH volume/time to presentation of at least 5 ml/hr. Intensive BP reduction was associated with a significantly lower rate of hematoma growth in fast bleeding patients (20.6% vs 31.0%, p = 0.005). In a subgroup of 266 (46.9%) fast-bleeding patients who received treatment within 2 hours after symptom onset, intensive BP lowering was associated with improved functional independence (odds ratio [OR] = 1.98, 95% confidence interval [CI] = 1.06-3.69, p = 0.031). INTERPRETATION: Our results suggest that early use of intensive BP reduction may reduce hematoma growth and improve outcome in fast bleeding patients. ANN NEUROL 2023.
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BACKGROUND: We performed an analysis of a large intensive care unit electronic database to provide preliminary estimates of various blood pressure parameters in patients with acute stroke receiving intravenous (IV) antihypertensive medication and determine the relationship with in-hospital outcomes. METHODS: We identified the relationship between pre-treatment and post-treatment systolic blood pressure (SBP) and heart rate (HR)-related variables and in-hospital mortality and acute kidney injury in patients with acute stroke receiving IV clevidipine, nicardipine, or nitroprusside using data provided in the Medical Information Mart for Intensive Care (MIMIC) IV database. RESULTS: A total of 1830 patients were treated with IV clevidipine (n = 64), nicardipine (n = 1623), or nitroprusside (n = 143). The standard deviations [SDs] of pre-treatment SBP (16.3 vs. 13.7, p ≤ 0.001) and post-treatment SBP (15.4 vs. 14.4, p = 0.004) were higher in patients who died compared with those who survived, particularly in patients with intracerebral hemorrhage (ICH). The mean SBP was significantly lower post treatment compared with pre-treatment values for clevidipine (130.7 mm Hg vs. 142.5 mm Hg, p = 0.006), nicardipine (132.8 mm Hg vs. 141.6 mm Hg, p ≤ 0.001), and nitroprusside (126.2 mm Hg vs. 139.6 mm Hg, p ≤ 0.001). There were no differences in mean SDs post treatment compared with pre-treatment values for clevidipine (14.5 vs. 13.5, p = 0.407), nicardipine (14.2 vs. 14.6, p = 0.142), and nitroprusside (14.8 vs. 14.8, p = 0.997). The SDs of pre-treatment and post-treatment SBP were not significantly different in patients with ischemic stroke treated with IV clevidipine, nicardipine, or nitroprusside or for patients with ICH treated with IV clevidipine or nitroprusside. However, patients with ICH treated with IV nicardipine had a significantly higher SD of post-treatment SBP (13.1 vs. 14.2, p = 0.0032). CONCLUSIONS: We found that SBP fluctuations were associated with in-hospital mortality in patients with acute stroke. IV antihypertensive medication reduced SBP but did not reduce SBP fluctuations in this observational study. Our results highlight the need for optimizing therapeutic interventions to reduce SBP fluctuations in patients with acute stroke.
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PURPOSE: Bacterial meningitis remains a global threat due to its high mortality. It is estimated that >1.2 million cases of bacterial meningitis are reported annually. Intracranial vasculopathy is an important, under-documented complication, easily detected by transcranial Doppler (TCD) ultrasonography. Following the PRISMA Guidelines, we reviewed the utility of TCD in bacterial meningitis. METHODS: This is a systematic review of observational studies on the use of TCD in patients with CSF-proven bacterial meningitis. Characteristic changes in TCD parameters along the course of the disease, correlation of TCD findings with neuroimaging, and functional outcomes were evaluated. RESULTS: Nine studies were included with a total of 492 participants (mean age of 42). The most common TCD finding was intracranial arterial stenosis of the MCA (50%-82%) and ischemia (33%) was the predominant neuroimaging finding. The presence of an abnormal TCD finding increased the risk of poor outcomes as high as 70%. CONCLUSIONS: Patients diagnosed with bacterial meningitis who underwent TCD show alterations in cerebral blood flow, correlating with imaging findings and poor outcomes. It aids in the diagnosis of its sequelae and can predict the prognosis of its outcome. TCD is a cost-effective, reliable modality for diagnosing vasculopathy associated with bacterial meningitis. It may prove useful in our armamentarium of management. Large prospective studies with long-term follow-up data may help establish the use of TCD in bacterial meningitis.
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Meningites Bacterianas , Ultrassonografia Doppler Transcraniana , Humanos , Adulto , Ultrassonografia Doppler Transcraniana/métodos , Estudos Prospectivos , Meningites Bacterianas/complicações , Meningites Bacterianas/diagnóstico por imagem , Prognóstico , Velocidade do Fluxo SanguíneoRESUMO
BACKGROUND: In recent years, there have anecdotal reports of intra-arterial thrombolysis (IAT) for the treatment of spinal cord ischemia (SCI) with encouraging results. We describe a patient with acute cervical SCI who underwent IAT with Tenecteplase at our institution. CASE PRESENTATION: A 20-year-old man presented to the emergency department with a 12-hour history of progressive onset upper and lower extremity numbness, weakness, and urinary incontinence after sustaining a fall. MRI of cervical spine demonstrated T2 and STIR hyperintensity in the ventral aspect of the spinal cord spanning the C3, C4, and C5 levels suggestive of SCI. He demonstrated progression of neurologic deficits to C4 ASIA B spinal cord injury with complete loss of motor function, diminished sensation, and absent rectal tone. Emergent angiography was performed with prominent anterior spinal supply via the left ascending cervical artery. A total of 30 mg of Tenecteplase was administered intra-arterially in the bilateral vertebral arteries, bilateral ascending cervical arteries, and bilateral inferior thyroid arteries. Two-week post-intervention neurologic examination demonstrated improvement in injury level and severity. The patient was C6 ASIA C SCI, with 2/5 strength in the distal upper and lower extremities and improved sensation. CONCLUSION: IAT with Tenecteplase may be a feasible option for the treatment of acute spinal cord ischemia in carefully selected patients.
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Medula Cervical , Isquemia do Cordão Espinal , Masculino , Humanos , Adulto Jovem , Adulto , Tenecteplase , Medula Espinal , Isquemia do Cordão Espinal/diagnóstico por imagem , Isquemia do Cordão Espinal/tratamento farmacológico , Isquemia do Cordão Espinal/etiologia , Vértebras Cervicais/diagnóstico por imagem , Isquemia , Terapia TrombolíticaRESUMO
BACKGROUND AND AIMS: There is no clear consensus on ideal systolic blood pressure (SBP) target post-endovascular thrombectomy (EVT) in patients with acute ischemic stroke. This study intends to investigate the relationship between reducing SBP and clinical outcomes and to determine the therapeutic efficacy of moderate and intensive SBP reduction post EVT. METHODS: A comprehensive search was conducted across five electronic databases to identify studies relevant to our analysis. Data from these studies were then analyzed using pooled relative risk (RR) along with their corresponding 95 % confidence intervals (CI) for our categorical outcomes. functional independence at 90 days post-EVT was defined as a modified Rankin score (mRS) 0-2. RESULTS: Our meta-analysis included eight studies with 2922 patients: 1376 patients were treated with intensive SBP reduction, 306 with moderate SBP reduction, and 1243 with standard SBP reduction. There was no difference in the risk of functional independence at 90 days post-EVT with both intensive-SBP reduction (target 120-140 mmHg, relative risk (RR) =1.05, 95 % CI 0.82, 1.34, p = 0.72) and moderate-SBP reduction (>160 mm Hg) (RR= 0.95, 95 % CI 0.69, 1.31, p = 0.76) compared with standard SBP reduction (>180 mm Hg). The risk of symptomatic intracranial hemorrhage (sICH) did not significantly differ between standard-SBP reduction and intensive-SBP reduction (RR = 0.93, 95 % CI 0.66, 1.31, p = 0.36) or moderate-SBP reduction (0.72 (95 % CI [0.28, 1.87], p = 0.50) groups, respectively. Intensive-SBP reduction significantly decreased the risk of hemicraniectomy. CONCLUSIONS: We did not identify any difference in functional independence at 90 days in acute ischemic stroke patients with either intensive-SBP reduction or moderate-SBP reduction compared with standard SBP reduction post-EVT.
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Pressão Sanguínea , Procedimentos Endovasculares , AVC Isquêmico , Recuperação de Função Fisiológica , Trombectomia , Humanos , Trombectomia/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , AVC Isquêmico/fisiopatologia , AVC Isquêmico/diagnóstico , AVC Isquêmico/terapia , AVC Isquêmico/etiologia , Resultado do Tratamento , Fatores de Risco , Idoso , Fatores de Tempo , Masculino , Feminino , Pessoa de Meia-Idade , Estado Funcional , Anti-Hipertensivos/uso terapêutico , Avaliação da Deficiência , Idoso de 80 Anos ou maisRESUMO
INTRODUCTION: Urgent endovascular intervention is currently accepted as the primary and critical therapeutic approach to patients whose acute ischemic stroke results from a large arterial occlusion (LAO). In this context, one of the quality metrics most widely applied to the assessment of emergency systems performance is the "door-to-puncture" (D-P) time. We undertook a project to identify the subinterval of the D-P metric causing the most impact on workflow delays and created a narrowly focused project on improving such subinterval. METHODS: Using the DMAIC (i.e., define, measure, analyze, improve and control) approach, we retrospectively reviewed our quality stroke data for calendar year (CY) 2021 (i.e., baseline population), completed a statistical process control assessment, defined the various subintervals of the D-P interval, and completed a Pareto analysis of their duration and their proportional contribution to the D-P interval. We retooled our workflow based on these analyses and analyzed the data resulting from its implementation between May and December 2022 (i.e., outcome population). RESULTS: The baseline population included 87 patients (44 men; mean age = 67.2 years). Their D-P process was uncontrolled, and times varied between 35-235 minutes (Mean = 97; SD = 38.40). Their door to angiography arrival (D-AA) subinterval was significantly slower than their arrival to puncture (AA-P) (73.4 v. 23.5 minutes; p < 0.01), accounted for 73% of the average length of the D-P interval. The group page activation to angiography arrival (GP-AA) subinterval accounted for 41.5% of the entire D-AA duration, making it the target of our project. The outcome population originally consisted of 38 patients (15 men; mean age = 70.3 years). Their D-P process was controlled, its times varying between 43-177 minutes (Mean = 85.8; SD = 34.46), but not significantly difference than the baseline population (p = 0.127). Their target subinterval GP-AA varied between 0-37 minutes and was significantly improved from the baseline population (Mean = 13.21 v. 29.68; p < 0.001). CONCLUSIONS: It seems feasible and reasonable to analyze the subinterval components of complex quality metrics such as the D-P time and carry out more focused quality improvement projects. Care must be exercised when interpreting the impact on overall system performance, due to unexpected variations within interdependent subprocesses. The application of a robust and comprehensive LSS continuous quality improvement process in any CSC will have to include individualized focused projects that simultaneously control the different components of overall system performance.
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Procedimentos Endovasculares , AVC Isquêmico , Acidente Vascular Cerebral , Humanos , Masculino , Idoso , Gestão da Qualidade Total , Fluxo de Trabalho , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/terapia , Trombectomia/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Resultado do Tratamento , Tempo para o TratamentoRESUMO
BACKGROUND: Clinical practice recommendations guide healthcare decisions. This study aims to evaluate the strength and quality of evidence supporting the American Heart Association (AHA)/American Stroke Association (ASA) guidelines for aneurysmal subarachnoid hemorrhage (aSAH) and spontaneous intracerebral hemorrhage (ICH). METHODS: We reviewed the current AHA/ASA guidelines for aSAH and spontaneous ICH and compared with previous guidelines. Guidelines were classified based on the Class of recommendation (COR) and Level of evidence (LOE). COR signifies recommendation strength (COR 1: Strong; COR 2a: Moderate; COR 2b: Weak; COR 3: No Benefit/Harm), while LOE denotes evidence quality (LOE A: High-Quality; LOE B-NR: Moderate-Quality, Not Randomized; LOE B-R: Moderate-Quality, Randomized; LOE C-EO: Expert Opinion; LOE C-LD: Limited Data). RESULTS: For aSAH, we identified 84 recommendations across 15 guideline categories. Of these, 31% were classified as COR I, 30% as COR 2a, 17% as COR 2b, and 18% as COR 3. In terms of LOE, 7% were based on LOE A, 10% on LOE B-R, 65% on LOE B-NR, 14% on LOE C-LD, and 5% on LOE C-EO. Compared to previous guidelines, there was a 46% decrease in LOE A, a 45% increase in LOE B, and an 11% decrease in LOE C. For spontaneous ICH, 124 guidelines were identified across 31 guideline categories. Of these, 28% were COR I, 32% COR 2b, and 9% COR 3. For LOE, 4% were based on LOE A, 35% on LOE B-NR, and 42% on LOE C-LD. Compared to previous guidelines, there was a 78% decrease in LOE A, an 82% increase in LOE B, and a 14% increase in LOE C. This analysis highlights that less than a third of AHA/ASA guidelines are classified as the highest class of recommendation, with less than 10% based on the highest LOE. CONCLUSION: Less than a third of AHA/ASA guidelines on aSAH and spontaneous ICH are classified as the highest class of recommendation with less than 10% based on highest LOE. There appears to be a decrease in proportion of guidelines based on highest LOE in most recent guidelines.
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OBJECTIVES: The value of thrombectomy in patients with acute ischemic stroke cannot be understated. As such, whether these patients get access to this treatment can significantly impact their disease outcomes. We analyzed the trends in thrombectomy adoption between teaching and non-teaching hospitals in the United States, and their impact on overall patient care. MATERIALS AND METHODS: We conducted a retrospective analysis of hospital admissions in the Nationwide Inpatient Sample with a diagnosis of acute ischemic stroke between 2012 and 2020. We compared the annual total number and proportion of patients undergoing thrombectomy between teaching and non-teaching hospitals, and their corresponding outcomes. RESULTS: 3,823,490 and 1,875,705 patients were admitted to teaching and non-teaching hospitals during the study duration, respectively. The proportion of patients who underwent thrombectomy increased from 1.60% to 7.02% (p-value for trend p<0.001) in teaching hospitals and from 0.32% to 2.20% (p-value trend p<0.001) in non-teaching hospitals. The absolute increase in the number of acute ischemic stroke patients undergoing thrombectomy was highest in teaching hospitals particularly those with large bed size, an increase from 3635 patients in 2012 to 24,730 patients in 2020. Higher rates of intravenous thrombolysis and patient transfer prior to thrombectomy were seen in teaching hospitals compared with non-teaching hospitals. CONCLUSIONS: The study highlights disparities between teaching and non-teaching hospitals, with teaching hospitals showing a disproportionately higher rate of thrombectomy adoption in acute ischemic stroke patients. Further studies are needed to understand the barriers to the adoption of thrombectomy in non-teaching hospitals.
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OBJECTIVES: We sought to provide updated incidence and trend data for cerebral venous thrombosis (CVT) in the United States from 2016-2020, examine the impact of the COVID-19 pandemic on CVT, and identify predictors of in-hospital mortality. MATERIALS AND METHODS: Validated ICD-10 codes were used to identify discharges with CVT in the National Inpatient Sample (NIS). Sample weights were applied to generate nationally representative estimates, and census data were used to compute incidence rates. The first wave of the COVID-19 pandemic was defined as January-May 2020. Trend analysis was completed using Joinpoint regression. RESULTS: From 2016 to 2020, the incidence of CVT increased from 24.34 per 1,000,000 population per year (MPY) to 33.63 per MPY (Annual Percentage Change (APC) 8.6 %; p < 0.001). All-cause in-hospital mortality was 4.9 % [95 % CI 4.5-5.4]. On multivariable analysis, use of thrombectomy, increased age, atrial fibrillation, stroke diagnosis, infection, presence of prothrombotic hematologic conditions, lowest quartile of income, intracranial hemorrhage, and male sex were associated with in-hospital mortality. CVT incidence was similar comparing the first 5 months of 2020 and 2019 (31.37 vs 32.04; p = 0.322) with no difference in median NIHSS (2 [IQR 1-10] vs. 2 [1-9]; p = 0.959) or mortality (4.2 % vs. 5.6 %; p = 0.176). CONCLUSIONS: CVT incidence increased in the US from 2016 to 2020 while mortality did not change. Increased age, prothrombotic state, stroke diagnosis, infection, atrial fibrillation, male sex, lowest quartile of income, intracranial hemorrhage, and use of thrombectomy were associated with in-hospital mortality following CVT. During the first wave of the COVID-19 pandemic, CVT volumes and mortality were similar to the prior year.
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Fibrilação Atrial , COVID-19 , Trombose Intracraniana , Acidente Vascular Cerebral , Trombose Venosa , Humanos , Masculino , Pacientes Internados , Fibrilação Atrial/complicações , Pandemias , COVID-19/epidemiologia , COVID-19/complicações , Trombose Venosa/diagnóstico , Trombose Venosa/epidemiologia , Trombose Venosa/terapia , Trombose Intracraniana/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/terapiaRESUMO
The field of endovascular neurosurgery has experienced remarkable progress over the last few decades. Endovascular treatments have continued to gain traction as the advancement of technology, technique, and procedural safety has allowed for the expansion of treatment indications of various cerebrovascular pathologies. Interventions such as the coiling of intracranial aneurysms, carotid artery stenting, mechanical thrombectomy in the setting of ischemic stroke, and endovascular embolization of arteriovenous malformations have all seen transformations in their safety and efficacy, expanding the scope of endovascularly treatable conditions and offering new hope to patients who may have otherwise not been candidates for surgical intervention. Despite this notable progress, challenges persist, including complications associated with device deployment and questions regarding long-term outcomes. This article explores the advancements in endovascular neurosurgical techniques, highlighting the impact on patient care, outcomes, and the evolution of traditional surgical methods.
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Transtornos Cerebrovasculares , Procedimentos Endovasculares , Humanos , Transtornos Cerebrovasculares/cirurgia , Transtornos Cerebrovasculares/terapia , Embolização Terapêutica , Procedimentos Endovasculares/tendências , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/terapia , Stents , TrombectomiaRESUMO
BACKGROUND: The authors compare the effectiveness and safety of endovascular treatment (EVT) versus best medical management (BMM) in strokes attributable to acute basilar artery occlusion (BAO). METHODS: The present analysis was based on the ongoing, prospective, multicenter ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion) trial registry in China. Our analytic sample comprised 2134 patients recruited at 48 sites between 2017 and 2021 and included 462 patients who received BMM and 1672 patients who received EVT. We performed an inversed probability of treatment weighting analysis. Qualifying patients had to present within 24 hours of estimated BAO. The primary clinical outcome was favorable functional outcome (modified Rankin Scale score, 0-3) at 90 days. We also performed a sensitivity analysis with the propensity score matching-based and the instrumental variable-based analysis. RESULTS: In our primary analysis using the inversed probability of treatment weighting-based analysis, there was a significantly higher rate of favorable outcome at 90 days among EVT patients compared with BMM-treated patients (adjusted relative risk, 1.42 [95% CI, 1.19-1.65]; absolute risk difference, 11.8% [95% CI, 6.9-16.7]). The mortality was significantly lower (adjusted relative risk, 0.78 [95% CI, 0.69-0.88]; absolute risk difference, -10.3% [95% CI, -15.8 to -4.9]) in patients undergoing EVT. Results were generally consistent across the secondary end points. Similar associations were seen in the propensity score matching-based and instrumental variable-based analysis. CONCLUSIONS: In this real-world study, EVT was associated with significantly better functional outcomes and survival at 90 days. Well-designed randomized studies comparing EVT with BMM in the acute BAO are needed. REGISTRATION: URL: www.chictr.org.cn; Unique identifier: ChiCTR2000041117.
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Arteriopatias Oclusivas , Procedimentos Endovasculares , Acidente Vascular Cerebral , Arteriopatias Oclusivas/terapia , Artéria Basilar , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Humanos , Estudos Prospectivos , Sistema de Registros , Trombectomia/métodos , Resultado do TratamentoRESUMO
Background: The influence of different viral infections in patients with myocarditis is unknown. Myocarditis is an inflammatory disease of heart muscle that is commonly caused by viruses. The impact of different viral infections in patients with myocarditis is unknown. Methods: We conducted a retrospective cohort study using data between 2016-2020 in the National Inpatient Sample in the USA to evaluate admissions with myocarditis and concomitant viral infection. The outcomes of in-hospital mortality, length of stay (LoS), and cost, among patients hospitalized for myocarditis was evaluated. Results: A total of 27,050 hospital admissions for myocarditis were included and 6750 (25.0%) had a co-diagnosis of viral infection. Patients with myocarditis and viral infection had significantly higher mortality compared to those without viral infection (23.6% vs. 4.4%, p < 0.001). Viral infection was associated with increased in-hospital mortality (odds ratio (OR) 2.03, 95% CI 1.51 to 2.73, p < 0.001), greater median LoS (7 vs. 3 days, p < 0.001) and median hospitalization cost ($21,445 vs. $11,596, p < 0.001), compared to patients without viral infection. The rate of death was greatest for patients with a diagnosis of coronavirus disease 2019 (COVID-19), viral pneumonia and herpes zoster, respiratory syncytial virus, chronic hepatitis, and influenza which was 36.0%, 34.3%, 27.3%, 21.4%, 20.0%, and 14.5%, respectively. Conclusions: In conclusion, the diagnosis of viral infection is present in one in four patients hospitalized with myocarditis and is correlated with greater mortality, LoS, and in-hospital cost.
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In this review article, we aim to provide a summary of the discoveries and developments that were instrumental in the evolution of the Neurointerventional field. We begin with developments in the advent of Diagnostic Cerebral Angiography and progress to cerebral aneurysm treatment, embolization in AVMs and ischemic stroke treatment. In the process we discuss many persons who were key in the development and maturation of the field. A pivotal aspect to rapid growth in the field has been the multidisciplinary involvement of the different neuroscience specialties and therefore we close out our discussion with excitement about ongoing and future developments in the field with a focus on treatments in the non-cerebrovascular disease realm.
Assuntos
Embolização Terapêutica , Aneurisma Intracraniano , AVC Isquêmico , Humanos , Embolização Terapêutica/métodos , Procedimentos Neurocirúrgicos , Angiografia CerebralRESUMO
The aim of this review is to provide an overview of the use of antiplatelet medication in neurointervention, with a focus on the clinical indications for antiplatelet use in both preventing and reducing platelet aggregation. This review will cover current antiplatelet medications, pharmacokinetics, and pharmacodynamics. We will provide an overview of different endovascular devices and discuss the antiplatelet regimes in neurointervention, highlighting gaps in evidence and scope for future studies.Two randomized controlled trials have evaluated antiplatelet use in the setting of acute large vessel occlusion stroke, with neither demonstrating benefit in their overall cohorts. Evidence on antiplatelet medication for both acute and elective stenting for acute stroke and treatment of cerebral aneurysms is currently based on large case series, and practice in neurointervention has increasingly utilized dual antiplatelet regimes with clopidogrel and second-line agents like prasugrel and ticagrelor. Clopidogrel function testing has an increasing role in neurointerventional procedures, particularly for high metal surface area stents such as the braided flow diverter type stents. Intravenous glycoprotein IIB/IIIA inhibitors have been utilized for both acute bridging and rescue therapy.Antiplatelet decision making is complex, and there are few randomized control trials to guide clinical practice. Comparative trials to guide decision making remain important in both the acute and elective settings. Standardised protocols incorporating platelet function testing may play a role in assisting decision making until more robust clinical evidence is available, particularly in the context of acute neurointerventional stenting for stroke and ruptured cerebral aneurysms.
Assuntos
Aneurisma Intracraniano , Acidente Vascular Cerebral , Humanos , Inibidores da Agregação Plaquetária/uso terapêutico , Inibidores da Agregação Plaquetária/farmacologia , Clopidogrel , Ticagrelor , Acidente Vascular Cerebral/tratamento farmacológico , Resultado do TratamentoRESUMO
The factors associated with cerebral infarction and mortality in patients hospitalized with intracardiac thrombus are unknown. A retrospective cohort study was undertaken of nationally representative hospital admissions in the National Inpatient Sample with a diagnosis of intracardiac thrombus between 2016 to 2019. Multiple logistic regressions were used to define factors associated with cerebral infarction and in-hospital mortality. There were a total of 175,370 admissions for patients with intracardiac thrombus and 10.1% patients had cerebral infarction (n = 17,675). Intracardiac thrombus represented 4.4% of primary diagnosis for admissions while circulatory conditions (65.4%), infection (5.9%), gastrointestinal conditions (4.4%), respiratory conditions (4.4%) and cancer (2.2%) were the other prevalent primary diagnoses. All-cause mortality was higher for patients with cerebral infarction (8.5% vs 4.8%). The five factors most associated with cerebral infarction were nephrotic syndrome (OR 2.67 95%CI 1.05-6.78), other thrombophilia (OR 2.12 95%CI 1.52-2.95), primary thrombophilia (OR 1.99 95%CI 1.52-2.53), previous stroke (OR 1.61 95%CI 1.47-1.75) and hypertension (OR 1.41 95%CI 1.27-1.56). The strongest independent predictors of death were heparin induced thrombocytopenia (OR 2.45 95%CI 150-4.00), acute venous thromboembolism (OR 2.03 95%CI 1.78-2.33, p < 0.001) acute myocardial infarction (OR 1.95 95%CI 1.72-2.22), arterial thrombosis (OR 1.75 95%CI 1.39-2.20) and cancer (OR 1.57 95%CI 1.36-1.81). Patients with intracardiac thrombus are at risk of cerebral infarction and in-hospital mortality. Nephrotic syndrome, thrombophilia, previous stroke, hypertension, and heparin induced thrombocytopenia were associated with cerebral infarction, while acute venous thromboembolism, acute myocardial infarction, and cancer were predictors of mortality.
Assuntos
Cardiopatias , Hipertensão , Infarto do Miocárdio , Síndrome Nefrótica , Acidente Vascular Cerebral , Trombocitopenia , Trombofilia , Trombose , Tromboembolia Venosa , Humanos , Pacientes Internados , Estudos Retrospectivos , Mortalidade Hospitalar , Hospitais , Infarto Cerebral , Fatores de RiscoRESUMO
BACKGROUND: Cilostazol, a phosphodiesterase III inhibitor, appears to be a promising agent for preventing cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage. Here, the authors perform a systematic review and meta-analysis to quantitatively assess the effects of cilostazol on brain structural and functional outcomes in animal models of cerebral ischemia and subarachnoid hemorrhage-induced cerebral vasospasm. METHODS: By using the PRISMA guidelines, a search of the PubMed, Scopus, and Web of Science was conducted to identify relevant studies. Study quality of each included study for both systematic reviews were scored by using an adapted 15-item checklist from the Collaborative Approach to Meta-Analysis of Animal Data from Experimental Studies. We calculated a standardized mean difference as effect size for each comparison. For each outcome, comparisons were combined by using random-effects modeling to account for heterogeneity, with a restricted maximum likelihood estimate of between-study variance. RESULTS: A total of 22 (median [Q1, Q3] quality score of 7 [5, 8]) and 6 (median [Q1, Q3] quality score of 6 [6, 6]) studies were identified for cerebral ischemia and subarachnoid hemorrhage-induced cerebral vasospasm, respectively. Cilostazol significantly reduced the infarct volume in cerebral ischemia models with a pooled standardized mean difference estimate of - 0.88 (95% confidence interval [CI] [- 1.07 to - 0.70], p < 0.0001). Cilostazol significantly reduced neurofunctional deficits in cerebral ischemia models with a pooled standardized mean difference estimate of - 0.66 (95% CI [- 1.06 to - 0.28], p < 0.0001). Cilostazol significantly improved the basilar artery diameter in subarachnoid hemorrhage-induced cerebral vasospasm with a pooled standardized mean difference estimate of 2.30 (95% CI [0.94 to 3.67], p = 0.001). Cilostazol also significantly improved the basilar artery cross-section area with a pooled standardized mean estimate of 1.88 (95% CI [0.33 to 3.43], p < 0.05). Overall, there was between-study heterogeneity and asymmetry in the funnel plot observed in all comparisons. CONCLUSIONS: Published animal data support the overall efficacy of cilostazol in reducing infarct volume and neurofunctional deficits in cerebral ischemia models and cerebral vasospasm in subarachnoid hemorrhage models.
Assuntos
Isquemia Encefálica , Hemorragia Subaracnóidea , Vasoespasmo Intracraniano , Animais , Cilostazol/farmacologia , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/tratamento farmacológico , Vasoespasmo Intracraniano/tratamento farmacológico , Vasoespasmo Intracraniano/etiologia , Funções Verossimilhança , Infarto Cerebral , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/etiologia , Modelos AnimaisRESUMO
BACKGROUND AND PURPOSE: Although many stroke centers in United States are using intravenous (IV) tenecteplase (TNK) for acute ischemic stroke patients, there is paucity of comparative data between IV TNK and IV alteplase from real-world settings. MATERIALS AND METHODS: We analyzed the data from 122 healthcare facilities in Cerner Real World Data and included patients admitted between February 2016 to April 2022 to determine the effect of IV TNK (compared with IV alteplase) on occurrence of two outcomes in acute ischemic stroke patients stratified by use of thrombectomy: non-routine discharge or death, and intracranial hemorrhage after adjusting for potential confounders. RESULTS: Among 30,643 acute ischemic stroke patients analyzed, 29,480 (96.2%) and 1,163 (3.8%) patients received IV alteplase and IV TNK, respectively. The proportion of patients who received thrombectomy was significantly higher among patients who received IV TNK compared with those who received IV alteplase (16.7% versus 11.0%, p<0.001). Occurrence of intracranial hemorrhage was more common among patients treated with IV TNK in acute ischemic stroke patients who did not receive thrombectomy (7.9% versus 5.1%, p<0.001) but not in those who received thrombectomy (20.1% versus 16.8%, p = 0.234). In the logistic regression analysis, patients treated with IV TNK who did not receive thrombectomy were at higher risk of intracranial hemorrhage (OR, 1.34, 95% CI 1.05-1.72, p = 0.02) after adjusting for age (age strata), gender, race/ethnicity, hypertension, diabetes mellitus, atrial fibrillation, hyperlipidemia, malignancy, nicotine dependence, previous ischemic stroke, previous transient ischemic attack, previous intracerebral hemorrhage, previous subarachnoid hemorrhage, previous acute myocardial infarction, atherosclerosis of aorta, previous AKI, congestive heart failure, peripheral vascular disease, and hospital type, aphasia, hemiplegia, neglect, somnolence, stupor and coma, dysphagia, and homonymous hemianopsia. There was no difference in the rate of non-routine discharge or death between patients treated with IV TNK and those treated with IV alteplase in the multivariate analyses. CONCLUSIONS: In an analysis of real-world data, IV TNK was associated with higher rates of intracranial hemorrhage compared with IV alteplase in patients with acute ischemic stroke who did not undergo thrombectomy.