Direct Oral Anticoagulant Failures in Atrial Fibrillation With Stroke: Retrospective Admission Analysis and Novel Classification System.

Introduction: Breakthrough acute ischemic stroke (AIS) in patients with known, nonvalvular Atrial Fibrillation (AF), on Direct Oral Anticoagulants (DOAC), is an ongoing clinical conundrum. Switching anticoagulants was shown to be ineffective in preventing recurrent AIS. Systematic, patient-level chart review of so-called "DOAC failures" may offer insight into this phenomenon. Methods: We conducted an IRB-approved, 6-year, retrospective study of AIS admissions, already prescribed DOAC for known AF. We sought plausible, alternative reasons for the AIS using a novel classification schema, CLAMP: C for Compliance concerns, L for Lacunes (small-vessel disease), A for Arteriopathy (atherosclerosis, web, or vasculitis), M for Malignancy, and P for Patent Foramen Ovale (PFO). These categories were labeled as DOAC "Pseudo-failures." Conversely, absence of CLAMP variables were labeled as DOAC "Crypto-failures" conceivably from AF itself ("atriopathy") or pharmacokinetic/pharmacogenomic dysfunction (ie, altered DOAC absorption, clearance, metabolism, or genetic polymorphisms). Forward logistic regression analysis was performed on prespecified DOAC subgroups. Results: Of 4890 AIS admissions, 606 had AF, and 87 were previously prescribed DOAC (14.4% overall DOAC failure rate, 2.4% annualized over 6 years). Pseudo-failures comprised 77%: Compliance concerns (48.9%), Lacunes (5.7%), Arteriopathy (17.0%), Malignancy (26.1%), and PFO (2.3%). Crypto-failures comprised 23%, had lower CHADSVASc scores (AOR = .65, P = .013), and occurred more with rivaroxaban (41%) than apixaban (16%) or dabigatran (5.6%). Conclusion: In AIS patients with known AF, DOAC Pseudo-failures, with identified alternate etiologies, are 3 times more likely than DOAC Crypto-failures. The CLAMP schema represents a novel approach to diagnostic classification and therapeutic adjustments in patients already prescribed DOAC for AF.

Prevalence and Impact of Aphasia among Patients Admitted with Acute Ischemic Stroke.

OBJECTIVE: Aphasia is one of the most severe symptoms in stroke patients, affecting one-third of acute stroke patients. We aimed to investigate the prevalence and outcomes of aphasia in patients with acute ischemic stroke (AIS). METHODS: We computed the weighted prevalence of aphasia in AIS patients using the 2003 to 2014 National Inpatient Sample databases. Crude regression model, multivariable regression model, and propensity score matching were used to evaluate the impact of aphasia on the clinical outcomes in AIS patients. We performed the Subpopulation Treatment Effect Pattern Plot (STEPP) analyses in propensity score matching cohort to visually display the effect of interaction between aphasia and age on the clinical outcomes. RESULTS: A total of 16.93% of 4,339,156 AIS patients identified were with aphasia. The proportion of patients with comorbid aphasia increased from 13.34% in 2003 to 21.94% in 2014 (P < .0001). The results of both multivariable regression model and propensity score matching analyses indicated aphasia in AIS as a risk factor for in-hospital deaths. Aphasia was linked to prolonged length of stay (0.66 day, P < .0001) and high hospitalization cost ($971.35, P < .0001). In the STEPP analyses, in-hospital mortality rate increased with age, and the rate was higher in patients with aphasia, but the ratios decreased with an increase in age. CONCLUSIONS: Prevalence of comorbid aphasia with AIS is increasing, and it has a significant impact on clinical outcomes. Additionally, aphasia shows a greater impact on survival and medical burden among young patients with AIS.

Associations of depression, anxiety and PTSD with neurological disability and cognitive impairment in survivors of moyamoya disease.

Depression, anxiety and posttraumatic stress disorder (PTSD) are common complications of cerebrovascular diseases. However, they were seldom explored in Moyamoya Disease (MMD) survivors. In this study, we measured the prevalence of depression, anxiety and PTSD in MMD survivors. We evaluated the association of mental disorders with neurological disability and cognitive impairment, and further find out the independent protective and risk factors of neurological disability and cognitive impairment. In MMD survivors, the prevalence of these three mental disorders is high, 46.7% for depression, 50% for anxiety and 47.5% for PTSD. Anxiety and PTSD were significantly associated with more severe neurological disability (p = 0.039 and < 0.001); depression and anxiety were significantly associated with greater cognitive deficiency (p = 0.004 and 0.002). We further found PTSD was the only risk factor associated with neurological disability, and the corresponding odds ratio (OR) and 95% confidence interval (CI) was 81.74 (9.91-674.17); depression and anxiety were risk factors associated with cognitive impairment, and the corresponding OR and 95%CI were 2.73 (1.10-6.81) and 3.37 (1.29-8.78). Therefore, these three mental disorders were associated with more severe neurological disability and greater cognitive deficiency in MMD survivors.

Role of diffusion tensor imaging or magnetic resonance spectroscopy in the diagnosis and disability assessment of amyotrophic lateral sclerosis.

OBJECTIVE: To compare the results of magnetic resonance spectroscopy (MRS) and diffusion tensor imaging (DTI) in amyotrophic lateral sclerosis (ALS) patients. METHODS: Nineteen ALS patients and thirteen age-matched healthy controls underwent MRS and DTI between October 2013 and July 2014. Fractional anisotropy (FA), apparent diffusion coefficient (ADC), N-acetylaspartate (NAA), choline (Cho), and creatine (Cr) were collected as the quantitative results of the imaging study. The ALS functional rating scale-revised (ALSFRS-R) and disease progression rate were evaluated to assess patients' disability. The imaging study results were compared between ALS patients and healthy controls. The relationship between disability assessment and imaging study results was analyzed. RESULTS: NAA/Cr in the motor cortex and FA in the corticospinal tract (CST) of both sides were significantly lower in patients than controls. There was no significant difference between the two groups in Cho/Cr, tract length, tract volume, ADC or NAA. No relationship was found between ALSFRS-R and FA (r=0.243, p=0.316) in the right CST; NAA (r=0.095, p=0.699) or NAA/Cr (r=0.172, p=0.481) in the left motor cortex; or NAA (r=0.320, p=0.182) or NAA/Cr (r=0.193, p=0.492) in the right motor cortex. There was no relationship between the disease progression rate and FA, NAA, or NAA/Cr on either side. CONCLUSION: NAA/Cr and FA can help diagnose ALS. Regional brain NAA/Cr and FA values could not assess the ALSFRS-R or disease progression rate.

Effect of piracetam on the cognitive performance of patients undergoing coronary bypass surgery: A meta-analysis.

Cognitive impairments are observed in numerous patients following coronary bypass surgery, and piracetam are nootropic compounds that modulate cerebral functions by directly enhancing cognitive processes. The present meta-analysis was conducted to evaluate the protective effect of piracetam on the cognitive performance of patients undergoing coronary bypass surgery. The relevant studies were identified by searching Medline, EMBASE, PubMed and the Cochrane Library up to June 2013 and the pertinent bibliographies from the retrieved studies were reviewed. Data were selected from the studies according to predefined criteria. The meta-analysis included two randomized control trials involving 184 patients and including the Syndrom-Kurz test (SKT). Findings of the meta-analysis showed that following treatment the change from baseline observed in five SKT subtest scores, conducted with piracetam patients, indicated a significant advantage over those patients that were in the placebo group. The subtests included immediate pictured object recall, weighted mean difference (WMD)=0.91, 95% confidence interval (CI) 0.51-1.31, P<0.00001; delayed pictured object recall, WMD=0.74, 95% CI 0.19-1.28, P=0.008; delayed picture recognition, WMD=0.82, 95% CI 0.31-1.31, P=0.001; immediate word recall, WMD=0.87, 95% CI 0.47-1.28, P<0.0001; and letter interference, WMD=3.46, 95% CI -5.69 to -1.23, P=0.002. These results indicated that piracetam may have been effective in improving the short-term cognitive performance of patients undergoing coronary bypass surgery. High quality, well-controlled and longer randomized trials are required to corroborate this result.