Thrombectomy with embed aspiration in acute ischaemic stroke.

BACKGROUND: In addition to stent retrievers, direct aspiration has become a reasonable thrombectomy strategy. OBJECTIVES: We carried out the thrombectomy by guiding the aspiration catheter fully over the clot and performing immediate manual aspiration; we call this procedure "embed aspiration". METHODS: In this prospective, non-randomised, single-centre study, we included all patients treated at a high volume-of-care stroke centre between 2017 and 2018 for the TRIANA (Thrombectomy in Andalusia using Aspiration) registry. Thrombectomy was carried out by embed aspiration. Patients were classified according to the success (eTICI 2b67-2c-3) or failure (eTICI 0-1-2a-2b50) of the procedure. Baseline clinical data and outcomes were compared, and multivariate analysis was performed. RESULTS: The embed aspiration technique was used in 370 patients. Treatment was successful in 90.3% of patients. Mean puncture-to-recanalisation time was 25 minutes. The overall rate of good outcomes (mRS 0-2) at 3 months was 64%. CONCLUSIONS: This study supports real-life evidence that standardised embed aspiration may be an alternative to stent retrievers for thrombectomy.

¿Ha dejado de disminuir la mortalidad por enfermedades cerebrovasculares en España? / Has stroke mortality stopped declining in Spain?

Objetivos: Analizar los cambios en las tendencias de la mortalidad por enfermedades cerebrovasculares según comunidad autónoma y sexo en España durante el período 1980-2016 utilizando modelos de regresión joinpoint. Métodos: Los datos de mortalidad se obtuvieron del Instituto Nacional de Estadística. Para cada comunidad autónoma y sexo se calcularon las tasas brutas y estandarizadas. El análisis de regresión joinpoint se utilizó para identificar los puntos más adecuados donde se produjo un cambio estadísticamente significativo en la tendencia. Resultados: El análisis joinpoint permite diferenciar comunidades en las que las tasas muestran un descenso continuado a lo largo de todo el periodo en ambos sexos (Asturias, Cantabria, Castilla y León, Ceuta y Melilla) o solo en los hombres (Extremadura). En los hombres, en las comunidades en las que se observan cambios en la tendencia se aprecia, en todas ellas (excepto en Aragón, Baleares y Murcia, donde las tasas permanecen estables), un primer periodo de descenso, que oscila entre el −3,4% en Cataluña y Extremadura y el −6,0% en Madrid, y un periodo final donde las tasas muestran tendencias divergentes: siguen descendiendo en Andalucía, Aragón, Baleares y Madrid, han comenzado a estabilizarse en Castilla-La Mancha y Murcia y aumentan en Canarias. En las mujeres, en las comunidades en que se observan cambios en la tendencia se aprecia, en todas ellas (excepto en Aragón, Murcia y País Vasco, donde las tasas permanecen estables), un primer periodo de descenso, que oscila entre el −3,1% en Cataluña y el −6,4% en Navarra, y un periodo final donde las tasas muestran tendencias divergentes: siguen descendiendo en Andalucía, Aragón, Cataluña, Galicia, Madrid y País Vasco, han comenzado a estabilizarse en Extremadura y Murcia, y aumentan en Canarias. [...] (AU)

Objectives: To analyse the changes in stroke mortality trends in Spain by autonomous community and by sex during the period 1980-2016, using joinpoint regression models. Methods: Mortality data were obtained from the Spanish National Statistics Institute. Crude and standardised rates were calculated for each Spanish autonomous community, and for each sex. Joinpoint analysis was used to identify the best-fitting points showing a statistically significant change in the trend. Results: Joinpoint analysis enabled us to differentiate between communities in which mortality rates showed a continuous decline throughout the study period in both sexes (Asturias, Cantabria, Castile and Leon, Ceuta, and Melilla) or in men only (Extremadura). In men, in all those communities in which changes in the trend were observed (all but Aragon, the Balearic Islands, and Murcia, where rates remained stable), we observed an initial period of decline (ranging from –3.4% in Catalonia and Extremadura, to –6.0% in Madrid) and a final period where the trends diverged: mortality rates continued to fall in Andalusia, Aragon, the Balearic Islands, and Madrid, but began to stabilise in Castile-La Mancha and Murcia and to increase in the Canary Islands. In women, in those communities where changes were observed (all but Aragon, Murcia, and the Basque Country, where rates remained stable), we observed an initial period of decline (ranging from –3.1% in Catalonia to –6.4% in Navarre) and a final period where divergent trends were observed: rates continued to decline in Andalusia, Aragon, Catalonia, Galicia, Madrid, and the Basque Country, but began to stabilise in Extremadura and Murcia and to increase in the Canary Islands. [...] (AU)

Has stroke mortality stopped declining in Spain?

OBJECTIVES: To analyse the changes in stroke mortality trends in Spain by autonomous community and by sex during the period 1980-2016, using joinpoint regression models. METHODS: Mortality data were obtained from the Spanish National Statistics Institute. Crude and standardised rates were calculated for each Spanish autonomous community, and for each sex. Joinpoint analysis was used to identify the best-fitting points showing a statistically significant change in the trend. RESULTS: Joinpoint analysis enabled us to differentiate between communities in which mortality rates showed a continuous decline throughout the study period in both sexes (Asturias, Cantabria, Castile and Leon, Ceuta, and Melilla) or in men only (Extremadura). In men, in all those communities in which changes in the trend were observed (all but Aragon, the Balearic Islands, and Murcia, where rates remained stable), we observed an initial period of decline (ranging from -3.4% in Catalonia and Extremadura, to -6.0% in Madrid) and a final period where the trends diverged: mortality rates continued to fall in Andalusia, Aragon, the Balearic Islands, and Madrid, but began to stabilise in Castile-La Mancha and Murcia and to increase in the Canary Islands. In women, in those communities where changes were observed (all but Aragon, Murcia, and the Basque Country, where rates remained stable), we observed an initial period of decline (ranging from -3.1% in Catalonia to -6.4% in Navarre) and a final period where divergent trends were observed: rates continued to decline in Andalusia, Aragon, Catalonia, Galicia, Madrid, and the Basque Country, but began to stabilise in Extremadura and Murcia and to increase in the Canary Islands. CONCLUSIONS: Current data show that stroke mortality rates have decreased (in women in Andalusia), stabilised (in both sexes in Murcia, in men in Castile-La Mancha, and in women in Extremadura), and have even reversed (in both sexes in the Canary Islands). Further study is needed to identify the causes of these trends.

Safety and outcomes of routine endovascular thrombectomy in large artery occlusion recorded in the SITS Register: An observational study.

BACKGROUND AND OBJECTIVE: We aimed to evaluate the safety and outcomes of thrombectomy in anterior circulation acute ischaemic stroke recorded in the SITS-International Stroke Thrombectomy Register (SITS-ISTR) and compare them with pooled randomized controlled trials (RCTs) and two national registry studies. METHODS: We identified centres recording ≥10 consecutive patients in the SITS-ISTR with at least 70% of available modified Rankin Scale (mRS) at 3 months during 2014-2019. We defined large artery occlusion as intracranial internal carotid artery, first and second segment of middle cerebral artery and first segment of anterior cerebral artery. Outcome measures were functional independence (mRS score 0-2) and death at 3 months and symptomatic intracranial haemorrhage (SICH) per modified SITS-MOST. RESULTS: Results are presented in the following order: SITS-ISTR, RCTs, MR CLEAN Registry and German Stroke Registry (GSR). Median age was 73, 68, 71 and 75 years; baseline NIHSS score was 16, 17, 16 and 15; prior intravenous thrombolysis was 62%, 83%, 78% and 56%; onset to reperfusion time was 289, 285, 267 and 249 min; successful recanalization (mTICI score 2b or 3) was 86%, 71%, 59% and 83%; functional independence at 3 months was 45.5% (95% CI: 44-47), 46.0% (42-50), 38% (35-41) and 37% (35-41), respectively; death was 19.2% (19-21), 15.3% (12.7-18.4), 29.2% (27-32) and 28.6% (27-31); and SICH was 3.6% (3-4), 4.4% (3.0-6.4), 5.8% (4.7-7.1) and not available. CONCLUSION: Thrombectomy in routine clinical use registered in the SITS-ISTR showed safety and outcomes comparable to RCTs, and better functional outcomes and lower mortality than previous national registry studies.

Has stroke mortality stopped declining in Spain? / ¿Ha dejado de disminuir la mortalidad por enfermedades cerebrovasculares en España?

OBJECTIVES: To analyse the changes in stroke mortality trends in Spain by autonomous community and by sex during the period 1980-2016, using joinpoint regression models. METHODS: Mortality data were obtained from the Spanish National Statistics Institute. Crude and standardised rates were calculated for each Spanish autonomous community, and for each sex. Joinpoint analysis was used to identify the best-fitting points showing a statistically significant change in the trend. RESULTS: Joinpoint analysis enabled us to differentiate between communities in which mortality rates showed a continuous decline throughout the study period in both sexes (Asturias, Cantabria, Castile and Leon, Ceuta, and Melilla) or in men only (Extremadura). In men, in all those communities in which changes in the trend were observed (all but Aragon, the Balearic Islands, and Murcia, where rates remained stable), we observed an initial period of decline (ranging from -3.4% in Catalonia and Extremadura, to -6.0% in Madrid) and a final period where the trends diverged: mortality rates continued to fall in Andalusia, Aragon, the Balearic Islands, and Madrid, but began to stabilise in Castile-La Mancha and Murcia and to increase in the Canary Islands. In women, in those communities where changes were observed (all but Aragon, Murcia, and the Basque Country, where rates remained stable), we observed an initial period of decline (ranging from -3.1% in Catalonia to -6.4% in Navarre) and a final period where divergent trends were observed: rates continued to decline in Andalusia, Aragon, Catalonia, Galicia, Madrid, and the Basque Country, but began to stabilise in Extremadura and Murcia and to increase in the Canary Islands. CONCLUSIONS: Current data show that stroke mortality rates have decreased (in women in Andalusia), stabilised (in both sexes in Murcia, in men in Castile-La Mancha, and in women in Extremadura), and have even reversed (in both sexes in the Canary Islands). Further study is needed to identify the causes of these trends.

Análisis de las tendencias en la mortalidad por enfermedades cerebrovasculares en España 1980-2011 / Analysis of cerebrovascular mortality trends in Spain from 1980 to 2011

Introducción: En las últimas décadas las tasas de mortalidad por enfermedades cerebrovasculares (ECV) han descendido de forma importante en muchos países. En este estudio se analizan los cambios recientes en la evolución de la mortalidad por ECV en España (1980-2011) para verificar si las tendencias observadas previamente continúan. Pacientes y métodos: Los datos de mortalidad por ECV y las poblaciones necesarias para el cálculo de los indicadores fueron facilitados por el Instituto Nacional de Estadística. Se calcularon las tasas específicas por grupos de edad y estandarizadas globales y truncadas (35-64 años) mediante el método directo (población estándar europea). Mediante análisis de regresión «joinpoint» estimamos el porcentaje de cambio anual de las tasas e identificamos puntos de cambio significativos en la tendencia. Resultados: La mortalidad por ECV se ha reducido de forma contundente y sostenida en los últimos 32 en todos los grupos de edad y sexo en España. En ambos sexos el análisis joinpoint identifica un periodo final de mayor descenso (2005-2011 [-6,3%] en mujeres y 2007-2011 en varones [-7,2%]). Conclusiones: Existe un marcado y continuo descenso en la mortalidad por ECV en España (1980-2011). Teniendo en cuenta el proceso de envejecimiento de la población, es esperable un incremento de la prevalencia y, por ello, de la magnitud de las ECV medida en términos de discapacidad y costes de salud, lo que representará un gran reto para nuestro sistema sanitario

Introduction: In recent decades, mortality rates for cerebrovascular diseases (CVD) have declined significantly in many countries. This study analyses changes in CVD mortality rates in Spain (1980-2011) to determine if previously observed trends remain. Patients and methods: Data on CVD mortality rates and the population data needed for the analysis were provided by Spain's National Statistics Institute. We calculated age-specific mortality rate, age-standardised overall mortality, and age-truncated mortality (35-64 years) using the direct method and standard European population structure. Joinpoint analysis was used to estimate the percentage of annual change in rates and identify significant changes in trends. Results: CVD mortality rate decreased considerably and continuously over the last 32 years in all age groups and in both sexes in Spain. For both sexes, joinpoint analysis identifies a final period with more marked decline: 2005-2011 in women (−6.3%) and 2007-2011 in men (−7.2%). Conclusions: CVD mortality rates displayed a marked and continuous decline in Spain between 1980 and 2011. Due to the ageing of the population, doctors expect an increase in CVD prevalence and therefore its magnitude in terms of disability and healthcare costs, which poses a challenge to our health system

Effect of CYP2C19 Polymorphisms on the Platelet Response to Clopidogrel and Influence on the Effect of High Versus Standard Dose Clopidogrel in Carotid Artery Stenting.

OBJECTIVES: Genetic background has been identified to be a major predictor of post-clopidogrel platelet inhibition in patients undergoing coronary stenting. However, there is a lack of data on clopidogrel response regarding genotype in patients undergoing carotid artery stenting (CAS). The influence of the most common allelic variants of CYP2C19 phenotypes and genotypes on response to baseline clopidogrel and on the pharmacodynamic effect of dose adjustment (high or standard dose of clopidogrel) in patients with high on-treatment reactivity after CAS was investigated. METHODS: Platelet reactivity was assessed before and 30 days after carotid stenting using the VerifyNow P2Y12 assay to obtain P2Y12 reactivity unit (PRU) values. RESULTS: A total of 209 patients (79.4% male, 44.1% currents smokers) were treated by CAS. Smokers improved responsiveness to clopidogrel (p = .034). With respect to CYP2C19 enzymatic function, 61 subjects (29.1%) were ultra-rapid metabolizers, 95 patients (45.5%) were extensive metabolizers, 51 (24.4%) were intermediate metabolizers, and two (0.96%) were poor metabolizers. Baseline PRU was significantly higher among intermediate-poor metabolizers compared with ultra-rapid (p = .001) or extensive metabolizers (p = .005). At 30 days follow up, in non-responding patients with the intermediate-poor metabolizer phenotype, the PRU value and inhibition percentage were significantly reduced with standard dose (p = .008; p = .0029) and high dose of clopidogrel (p = .00 0; p = .000). However, high dose clopidogrel did not achieve a more intense pharmacodynamic effect at 30 days (p = .994) compared with standard dose. CONCLUSIONS: In patients undergoing carotid stenting, those with the CYP2C19*2 allele had increased basal PRU values and in fact clopidogrel non-responders increased significantly among intermediate-poor metabolizers. Although high dose and standard dose clopidogrel therapy was effective in lowering the 30 day PRU values in patients with high on-treatment reactivity who are intermediate-poor metabolizers, the use of high dose clopidogrel did not result in statistically significantly greater reductions in reactivity compared with the standard dose.

Analysis of cerebrovascular mortality trends in Spain from 1980 to 2011. / Análisis de las tendencias en la mortalidad por enfermedades cerebrovasculares en España 1980-2011.

INTRODUCTION: In recent decades, mortality rates for cerebrovascular diseases (CVD) have declined significantly in many countries. This study analyses changes in CVD mortality rates in Spain (1980-2011) to determine if previously observed trends remain. PATIENTS AND METHODS: Data on CVD mortality rates and the population data needed for the analysis were provided by Spain's National Statistics Institute. We calculated age-specific mortality rate, age-standardised overall mortality, and age-truncated mortality (35-64 years) using the direct method and standard European population structure. Joinpoint analysis was used to estimate the percentage of annual change in rates and identify significant changes in trends. RESULTS: CVD mortality rate decreased considerably and continuously over the last 32 years in all age groups and in both sexes in Spain. For both sexes, joinpoint analysis identifies a final period with more marked decline: 2005-2011 in women (-6.3%) and 2007-2011 in men (-7.2%). CONCLUSIONS: CVD mortality rates displayed a marked and continuous decline in Spain between 1980 and 2011. Due to the ageing of the population, doctors expect an increase in CVD prevalence and therefore its magnitude in terms of disability and healthcare costs, which poses a challenge to our health system.

Descripción de una serie de 10 pacientes con cefalea hípnica: discusión de criterios diagnósticos / Description of series of 10 patients with hypnic headache: Discussion of the diagnostic criteria

Introducción: La cefalea hípnica es una cefalea primaria poco frecuente. Los criterios diagnósticos de la Clasificación Internacional de Cefaleas (CIC) para esta entidad han sido discutidos, por lo que en la nueva edición de la CIC de 2013 se han modificado. Pacientes y métodos: Analizamos las características clínicas y la adecuación a los criterios de la CIC de una serie de 10 pacientes diagnosticados en nuestra consulta de cefaleas. Resultados: La edad media de inicio del cuadro fue 52,1 años (DE: 13,4; rango: 28-69). El 60% de nuestros pacientes describían el dolor como opresivo y el 30% como punzante. En el 60% es holocraneal y en el 40% es hemicraneal. Al 80% les ocurre exclusivamente durante el sueño nocturno. La duración media de la cefalea es de 136,5 min (rango: 10-480). La media de días al mes es de 16.4 (rango: 3-30) y el 50% presentaron cefalea menos de 15 días al mes. Ningún paciente presentó manifestaciones autonómicas, el 70% presentó sonofobia y el 50% fotofobia. El 50% presentó ambas. El 100% puntuó la intensidad en la escala VAS igual o superior a 8. Conclusiones: Los criterios para cefalea hípnica de la nueva CIC se adecuan mejor a las características de estos pacientes. Nuestros resultados reflejan los principales cambios en los criterios: el dolor no siempre es sordo, puede aparecer menos de 15 días al mes y en personas de menos de 50 años. Puede existir sonofobia y fotofobia y no solo uno de ellos. Aunque no forma parte de los criterios diagnósticos, nos ha llamado la atención que en nuestra serie la intensidad es mayor a la descrita

Introduction: Hypnic headache is a rare primary headache. The diagnostic criteria of the International Headache Classification (IHS) for this condition are discussed, as they have been modified in the new edition of the 2013. Patients and methods: The clinical characteristics, and fulfilment of the criteria of the IHS classification in a series of 10 patients diagnosed in our Headaches Clinic, are analyzed. Results: The mean age of onset of symptoms was 52.1 years (SD: 13.4; range: 28-69). The pain was reported as oppressive in 60% of the patients, and as sharp in 30%. The headache was described as holocranial in 60% and hemicranial in 40%. They occurred exclusively during night-time sleep in 80% of the patients. The mean duration of headache was 136.5 minutes (range: 10-480). The mean number of days per month was 16.4 (range: 3-30), and 50% had less than 15 headache days per month. No patient had autonomic manifestations, 70% had phonophobia, 50% had photophobia, and 50% had both. All of them (100%) had a VAS score equal to or higher than 8. Conclusions: The criteria for hypnic headache of the new classification are best suited to the characteristics of these patients. Our results show the major changes in the criteria: pain is not always dull, headache frequency may be less than 15 days a month, and it can occur in people under age 50. There may be phonophobia or photophobia only, or both. Although it does not form part of the diagnostic criteria, the pain intensity in our series was higher than described

Description of series of 10 patients with hypnic headache: Discussion of the diagnostic criteria.

INTRODUCTION: Hypnic headache is a rare primary headache. The diagnostic criteria of the International Headache Classification (IHS) for this condition are discussed, as they have been modified in the new edition of the 2013. PATIENTS AND METHODS: The clinical characteristics, and fulfilment of the criteria of the IHS classification in a series of 10patients diagnosed in our Headaches Clinic, are analyzed. RESULTS: The mean age of onset of symptoms was 52.1years (SD: 13.4; range: 28-69). The pain was reported as oppressive in 60% of the patients, and as sharp in 30%. The headache was described as holocranial in 60% and hemicranial in 40%. They occurred exclusively during night-time sleep in 80% of the patients. The mean duration of headache was 136.5minutes (range: 10-480). The mean number of days per month was 16.4 (range: 3-30), and 50% had less than 15 headache days per month. No patient had autonomic manifestations, 70% had phonophobia, 50% had photophobia, and 50% had both. All of them (100%) had a VAS score equal to or higher than 8. CONCLUSIONS: The criteria for hypnic headache of the new classification are best suited to the characteristics of these patients. Our results show the major changes in the criteria: pain is not always dull, headache frequency may be less than 15days a month, and it can occur in people under age 50. There may be phonophobia or photophobia only, or both. Although it does not form part of the diagnostic criteria, the pain intensity in our series was higher than described.

[Diffuse brain involvement in paediatrics: magnetic resonance findings]. / Afectación difusa del cerebelo en la edad pediátrica: hallazgos en resonancia magnética.

Posterior fossa involvement, which may be focal or diffuse, is an uncommon finding in paediatric patients. Acute cerebellitis is the first condition to be suspected among the diffuse forms, and ataxia is the most characteristic symptom. This condition is occasionally difficult to diagnose clinically, thus imaging tests play an important role in this. However, there are other rare conditions which may be clinically and radiologically similar to acute cerebellitis and which should be taken into account when making a differential diagnosis. The aim of this article is to present five diseases with diffuse brain involvement in paediatric patients and describe how they show up in MR imaging.