Influence of Hospital Type on Outcomes of Patients With Acute Spontaneous Intracerebral Hemorrhage: A Population-Based Study.

BACKGROUND AND OBJECTIVES: Whether the outcome of patients with spontaneous intracerebral hemorrhage (ICH) differs depending on the type of hospital where they are admitted is uncertain. The objective of this study was to determine influence of hospital type at admission (telestroke center [TSC], primary stroke center [PSC], or comprehensive stroke center [CSC]) on outcome for patients with ICH. We hypothesized that outcomes may be better for patients admitted to a CSC. METHODS: This is a multicenter prospective observational and population-based study of a cohort of consecutively recruited patients with ICH (March 2020-March 2022). We included all patients with spontaneous ICH in Catalonia (Spain) who had a pre-ICH modified Rankin scale (mRS) score of 0-3 and who were admitted to the hospital within 24 hours of onset. We compared patients admitted to a TSC/PSC (n = 641) or a CSC (n = 1,320) and also analyzed the subgroup of patients transferred (n = 331) or not transferred (n = 310) from a TSC/PSC to a CSC. The main outcome was the 3-month mRS score obtained by blinded investigators. Outcomes were compared using adjusted ordinal logistic regression to estimate the common odds ratio (OR) and 95% CI for a shift in mRS scores. A propensity score matching (PSM) analysis was performed for the subgroup of transferred patients. RESULTS: Relevant data were obtained from 1961 of a total of 2,230 patients, with the mean (SD) age of 70 (14.1) years, and 713 (38%) patients were women. After adjusting for confounders (age, NIH Stroke Scale score, intraventricular hemorrhage, hematoma volume, and pre-ICH mRS score), type of hospital of initial admission (CSC vs TSC/PSC) was not associated with outcome (adjusted common OR 1.13, 95% CI 0.93-1.38). A PSM analysis indicated that transfer to a CSC was not associated with more favorable outcomes (OR 0.77, 95% CI 0.55-1.10; p = 0.16). DISCUSSION: In this population-based study, we found that, after adjusting for confounders, hospital types were not associated with functional outcomes. In addition, for patients who were transferred from a TSC/PSC to a CSC, PSM indicated that outcomes were similar to nontransferred patients. Our findings suggest that patient characteristics are more important than hospital characteristics in determining outcome after ICH. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov Identifier: NCT03956485.

Early automated cerebral edema assessment following endovascular therapy: impact on stroke outcome.

BACKGROUND: Cerebral edema (CED) is associated with poorer outcome in patients with acute ischemic stroke (AIS). The aim of the study was to investigate the factors contributing to greater early CED formation in patients with AIS who underwent endovascular therapy (EVT) and its association with functional outcome. METHODS: We conducted a multicenter cohort study of patients with an anterior circulation AIS undergoing EVT. The volume of cerebrospinal fluid (CSF) was extracted from baseline and 24-hour follow-up CT using an automated algorithm. The severity of CED was quantified by the percentage reduction in CSF volume between CT scans (∆CSF). The primary endpoint was a shift towards an unfavorable outcome, assessed by modified Rankin Scale (mRS) score at 3 months. Multivariable ordinal logistic regression analyses were performed. The ∆CSF threshold that predicted unfavorable outcome was selected using receiver operating characteristic curve analysis. RESULTS: We analyzed 201 patients (mean age 72.7 years, 47.8% women) in whom CED was assessable for 85.6%. Higher systolic blood pressure during EVT and failure to achieve modified Thrombolysis In Cerebral Infarction (mTICI) 3 were found to be independent predictors of greater CED. ∆CSF was independently associated with the probability of a one-point worsening in the mRS score (common odds ratio (cOR) 1.05, 95% CI 1.03 to 1.08) after adjusting for age, baseline mRS, National Institutes of Health Stroke Scale (NIHSS), and number of passes. Displacement of more than 25% of CSF was associated with an unfavorable outcome (OR 6.09, 95% CI 3.01 to 12.33) and mortality (OR 6.72, 95% CI 2.94 to 15.32). CONCLUSIONS: Early CED formation in patients undergoing EVT was affected by higher blood pressure and incomplete reperfusion. The extent of early CED, measured by automated ∆CSF, was associated with worse outcomes.

Rationale and Design of the Statins Use in Intracerebral Hemorrhage Patients (SATURN) Trial.

INTRODUCTION: The benefits and risks of HMG-CoA reductase inhibitor (statin) drugs in survivors of intracerebral hemorrhage (ICH) are unclear. Observational studies suggest an association between statin use and increased risk of lobar ICH, particularly in patients with apolipoprotein-E (APOE) ε2 and ε4 genotypes. There are no randomized controlled trials (RCTs) addressing the effects of statins after ICH leading to uncertainty as to whether statins should be used in patients with lobar ICH who are at high risk for ICH recurrence. The SATURN trial aims to evaluate the effects of continuation versus discontinuation of statin on the risk of ICH recurrence and ischemic major adverse cerebro-cardio-vascular events (MACCE) in patients with lobar ICH. Secondary aims include the assessment of whether the APOE genotype modifies the effects of statins on ICH recurrence, functional and cognitive outcomes and quality of life. METHODS: The SATURN trial is a multi-center, pragmatic, prospective, randomized, open-label, Phase III clinical trial with blinded end-point assessment. A planned total of 1456 patients with lobar ICH will be recruited from 140 sites in the United States, Canada and Spain. Patients presenting within seven days of a spontaneous lobar ICH that occurred while taking a statin, will be randomized (1:1) to continuation (control) vs. discontinuation (intervention) of the same statin drug and dose that they were using at ICH onset. The primary outcome is the time to recurrent symptomatic ICH within a two-year follow-up period. The primary safety outcome is the occurrence of ischemic MACCE. CONCLUSION: The results will help to determine the best strategy for statin use in survivors of lobar ICH and may help to identify if there is a subset of patients who would benefit from statins.

A multitrait genetic study of hemostatic factors and hemorrhagic transformation after stroke treatment.

BACKGROUND: Thrombolytic recombinant tissue plasminogen activator (r-tPA) treatment is the only pharmacologic intervention available in the ischemic stroke acute phase. This treatment is associated with an increased risk of intracerebral hemorrhages, known as hemorrhagic transformations (HTs), which worsen the patient's prognosis. OBJECTIVES: To investigate the association between genetically determined natural hemostatic factors' levels and increased risk of HT after r-tPA treatment. METHODS: Using data from genome-wide association studies on the risk of HT after r-tPA treatment and data on 7 hemostatic factors (factor [F]VII, FVIII, von Willebrand factor [VWF], FXI, fibrinogen, plasminogen activator inhibitor-1, and tissue plasminogen activator), we performed local and global genetic correlation estimation multitrait analyses and colocalization and 2-sample Mendelian randomization analyses between hemostatic factors and HT. RESULTS: Local correlations identified a genomic region on chromosome 16 with shared covariance: fibrinogen-HT, P = 2.45 × 10-11. Multitrait analysis between fibrinogen-HT revealed 3 loci that simultaneously regulate circulating levels of fibrinogen and risk of HT: rs56026866 (PLXND1), P = 8.80 × 10-10; rs1421067 (CHD9), P = 1.81 × 10-14; and rs34780449, near ROBO1 gene, P = 1.64 × 10-8. Multitrait analysis between VWF-HT showed a novel common association regulating VWF and risk of HT after r-tPA at rs10942300 (ZNF366), P = 1.81 × 10-14. Mendelian randomization analysis did not find significant causal associations, although a nominal association was observed for FXI-HT (inverse-variance weighted estimate [SE], 0.07 [-0.29 to 0.00]; odds ratio, 0.87; 95% CI, 0.75-1.00; raw P = .05). CONCLUSION: We identified 4 shared loci between hemostatic factors and HT after r-tPA treatment, suggesting common regulatory mechanisms between fibrinogen and VWF levels and HT. Further research to determine a possible mediating effect of fibrinogen on HT risk is needed.

Perfil clínico y satisfacción con el tratamiento anticoagulante en pacientes con fibrilación auricular no valvular atendidos en consultas de medicina interna y neurología de España / Clinical profile and satisfaction with anticoagulated treatment in patients with non-valvular atrial fibrillation attended in Internal Medicine and Neurology departments of Spain

Objetivo. Determinar el perfil clínico, el manejo del tratamiento anticoagulante y la satisfacción relacionada con la anticoagulación en pacientes con fibrilación auricular no valvular atendidos en consultas de neurología o medicina interna de España. Pacientes y métodos. Estudio prospectivo, transversal y multicéntrico en el que se incluyó a 1.337 pacientes, que completaron los cuestionarios Anti-Clot Treatment Scale, Self-Assessment of Treatment Questionnaire y EuroQol-5 dimensions. Resultados. 865 pacientes (64,7%) provenían de consultas de neurología, y 472 (35,3%), de medicina interna. Los atendidos en medicina interna eran mayores, tenían más hipertensión, diabetes, insuficiencia cardíaca, insuficiencia renal y arteriopatía periférica. Los pacientes atendidos en neurología tenían más antecedentes de ictus. Globalmente, la escala CHADS2 fue 3,2 ± 1,3; CHA2DS2Vasc, 4,8 ± 1,5, y HAS-BLED, 2,0 ± 0,9, y las puntuaciones más altas fueron en neurología. El 56,1% tomaba antagonistas de la vitamina K, lo que era más común en medicina interna. El porcentaje de tiempo en rango terapéutico adecuado fue del 47% (Rosendaal), sin diferencias entre los grupos. La satisfacción con el tratamiento anticoagulante oral fue elevada en ambos grupos, aunque mayor en los sujetos atendidos en neurología, y mayor con los anticoagulantes orales de acción directa que con los antagonistas de la vitamina K. Conclusiones. Aunque existieron ciertas diferencias en el perfil clínico de los pacientes con fibrilación auricular atendidos en neurología o medicina interna, todos presentaban múltiples comorbilidades y un riesgo tromboembólico elevado. A pesar de que el control del índice internacional normalizado fue pobre, el anticoagulante oral más empleado fueron los antagonistas de la vitamina K. La satisfacción con el tratamiento anticoagulante oral fue alta (AU)

Aim. To determine the clinical profile, management of anticoagulant treatment and satisfaction related to anticoagulation in outpatients with nonvalvular atrial fibrillation attended in Neurology or Internal Medicine departments of Spain. Patients and methods. Cross-sectional and multicenter study, in which 1,337 outpatients were included. Patients fulfilled ACTS, SAT-Q and EQ-5D questionnaires. Results. 865 patients (64.7%) were recruited from Neurology department and 472 (35.3%) from Internal Medicine department. Those patients attended in Internal Medicine department were older and had more frequently hypertension, diabetes, heart failure, renal insufficiency and peripheral artery disease. Those patients attended in Neurology department had more commonly prior stroke. Overall, CHADS2 score was 3.2 ± 1.3, CHA2DS2-Vasc 4.8 ± 1.5 and HAS-BLED 2.0 ± 0.9. All scores were higher in those patients attended in Neurology department. Globally, 56.1% of patients were taking vitamin K antagonists, more commonly in Internal Medicine department. The adequate percent of time in therapeutic range was 47% (Rosendaal), without significant differences between groups. Satisfaction with oral anticoagulation was high in both groups, but higher in those attended in Neurology department, and higher in those individuals taking direct oral anticoagulants compared with vitamin K antagonists. Conclusions. Although there were some differences in the clinical profile of patients with atrial fibrillation attended in Neurology or Internal Medicine departments, all of them had many comorbidities and a high thromboembolic risk. Despite INR control was poor, the most common oral anticoagulant used were vitamin K antagonists. Satisfaction related to oral anticoagulation was high (AU)

Guía para el tratamiento preventivo del ictus isquémico y AIT (II). Recomendaciones según subtipo etiológico / Guidelines for the preventive treatment of ischaemic stroke and TIA (II). Recommendations according to aetiological sub-type

FUNDAMENTO Y OBJETIVO: Actualizar las guías terapéuticas del Comité ad hoc del Grupo de Estudio de Enfermedades Cerebrovasculares de la SEN en el tratamiento preventivo de ictus isquémico (II) y ataque isquémico transitorio (AIT). MÉTODOS: Revisión de evidencias disponibles sobre la prevención del ictus isquémico y AIT en función del subtipo etiológico. Los niveles de evidencia y grados de recomendación se han basado en la clasificación del Centro de Medicina Basada en la Evidencia. RESULTADOS: En el II de origen aterotrombótico reducen el riesgo de recurrencias el tratamiento antiagregante y los procedimientos revascularizadores en casos seleccionados de estenosis carotidea ipsilateral (70-99%). La prevención de II de origen cardioembólico (fibrilación auricular, valvulopatías, prótesis valvulares y en infarto de miocardio con trombo mural) se basa en el uso de anticoagulantes orales. En el II de origen inhabitual, las terapias preventivas dependerán de la etiología; en la trombosis venosa cerebral la anticoagulación oral es eficaz. CONCLUSIONES: Se concluye con recomendaciones de práctica clínica en prevención de ictus isquémico y AIT adaptadas al subtipo etiológico de II que ha presentado el paciente

BACKGROUND AND OBJECTIVE: To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke (IS) and Transient Ischaemic Attack (TIA). METHODS: We reviewed the available evidence on ischaemic stroke and TIA prevention according to aetiological subtype. Levels of evidence and recommendation levels are based on the classification of the Centre for Evidence-Based Medicine. RESULTS: In atherothrombotic IS, antiplatelet therapy and revascularization procedures in selected cases of ipsilateral carotid stenosis (70%-90%) reduce the risk of recurrences. In cardioembolic IS (atrial fibrillation, valvular diseases, prosthetic valves and myocardial infarction with mural thrombus) prevention is based on the use of oral anticoagulants. Preventive therapies for uncommon causes of IS will depend on the aetiology. In the case of cerebral venous thrombosis oral anticoagulation is effective. CONCLUSIONS: We conclude with recommendations for clinical practice in prevention of IS according to the aetiological subtype presented by the patient

Infartos cerebrales intrahospitalarios: datos del registro multicéntrico de pacientes con infarto cerebral ingresados en Cardiología y Cirugía Cardiaca / In-hospital ischemic strokes in patients admitted to Cardiology and Cardiac Surgery departments. Multi-centre registry

Fundamento y objetivo: Los pacientes ingresados en Cardiología y Cirugía Cardiaca tienen un riesgo importante de sufrir un infarto cerebral (IC). Analizamos las características clínicas, calidad de la atención neurológica y la evolución de los ictus intrahospitalarios (IIH) en estos servicios. Pacientes y método:Registro prospectivo de IC en pacientes ingresados en Cardiología y Cirugía Cardiaca en 13 hospitales españoles durante 2008. Recogemos datos demográficos, clínicos, terapéuticos, evolutivos y de mortalidad. Resultados: Registramos 73 casos. La edad media (DE) fue de 72 (11,6) años. El 75,4% de los IC fueron cardioembólicos. Como factores de riesgo para ictus destacaron: presencia de cardiopatías embolígenas (86,3%), suspensión del tratamiento antitrombótico previo (22%) y procedimientos invasivos (65,7%). La evaluación neurológica se hizo en menos de 3 horas en el 49,5% y pasadas 24 horas del IC en el 20,5%. Diez pacientes fueron tratados con trombólisis intravenosa, 8 no pudieron ser tratados por el retraso en avisar a Neurología. Entre las contraindicaciones para trombólisis destacaron la anticoagulación en rango (38%) y la cirugía reciente (33,3%). A los 3 meses, la mortalidad fue del 15% y solamente el 53,7% eran independientes. Los pacientes tratados con trombólisis tuvieron mejor evolución (87,5% de pacientes independientes, p=0,04).Conclusiones: Los IC intrahospitalarios en Cardiología y Cirugía Cardiaca son fundamentalmente cardioembólicos y producen una gran proporción de pacientes dependientes. Los pacientes tratados con trombólisis tuvieron mejor evolución clínica. El retraso en la llamada a Neurología impidió que una proporción relevante de pacientes fueran tratados con trombólisis intravenosa (AU)

Background and objective: Patients admitted to Cardiology and Cardiac Surgery Departments have an increased risk of ischemic stroke (IS). We analyzed clinical characteristics, quality of neurological care and mortality of in-hospital strokes (IHS) in these departments. Patients and method:Prospective registry of in-hospital ISs in Cardiology and Cardiac Surgery in 13 Spanish hospitals during 2008. Demographic, clinical and therapeutic data as well as mortality and functional evolution were recorded. Results: 73 patients were included. Mean age was 72±11.6 years. 75.4% of IS were cardioembolic. Special risk factors were presence of cardiac sources of embolism (86.3%), prior withdrawal of antithrombotic treatment (22%) and invasive procedures (65.7%). First neurological assessment was done in the first 3hours in 49.5% and beyond 24hours from IS onset in 20.5%. Ten patients were treated with intravenous thrombolysis, which was not possible in 8 patients because of the delay in calling the neurologist. Most frequent reasons for exclusion from thrombolytic therapy were recent major surgical procedures (33.3%) and anticoagulant therapy (38%). Three-month mortality was 15% and only 53.7% were functionally independent. Patients treated with thrombolysis had a better evolution (87.5% of independent patients, p=0.04). Conclusions: IS in Cardiology and Cardiac Surgery are mostly cardioembolic strokes and produce a high proportion of dependent patients. Patients treated with thrombolysis had a better evolution. Delays in contacting the neurologist led to exclusion from treatment an important proportion of patients who met thrombolysis criteria (AU)