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1.
J Am Heart Assoc ; 10(5): e017701, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33615836

RESUMO

Background Although antiplatelet agents are frequently prescribed in moyamoya disease in routine clinical practice, there are no large-scale epidemiologic trials or randomized trial evidence to support their use in patients with moyamoya disease. Methods and Results Using the Korean National Health Insurance Service database, patients diagnosed with moyamoya disease between 2002 and 2016 were followed up for up to 14 years to assess, using time-dependent Cox regression in all patients and in a propensity score-matched cohort, the association of antiplatelet therapy and individual antiplatelet agents with survival. Among 25 978 patients with newly diagnosed moyamoya disease, mean age was 37.6±19.9 years, 61.6% were women, and total follow-up was 163 347 person-years. Among 9154 patients who were prescribed antiplatelet agents at least once during the follow-up period, the proportion prescribed cilostazol gradually increased from 5.5% in 2002 to 56.0% in 2016. Any antiplatelet use was associated with reduced risk of death (hazard ratio, 0.77; 95% CI, 0.70-0.84) in a multivariate model. Among individual antiplatelet agents, cilostazol was associated with greater reduction in mortality than the 5 other antiplatelet regimens. Subgroup analysis, according to the age group and history of ischemic stroke, and sensitivity analysis, using propensity score-matched analysis, revealed consistent results. Conclusions Antiplatelet therapy is associated with substantial improvement in survival in patients with moyamoya disease, and cilostazol is associated with greater survival benefit compared with other antiplatelet regimens. These results provisionally support the use of antiplatelet therapy in patients with moyamoya disease and the conduct of confirmatory randomized controlled trials.

3.
Neurology ; 2021 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-33589538

RESUMO

OBJECTIVE: To evaluate the effect of intensive rehabilitation on the modified Rankin Scale (mRS), a measure of activities limitation commonly used in acute stroke studies, and to define the specific changes in body structure/function (motor impairment) most related to mRS gains. METHODS: Patients were enrolled >90 days post-stroke. Each was evaluated before and 30-days after a 6-week course of daily rehabilitation targeting the arm. Activity gains, measured using the mRS, were examined and compared to body structure/function gains, measured using the Fugl-Meyer (FM) motor scale. Additional analyses examined whether activity gains were more strongly related to specific body structure/function gains. RESULTS: At baseline (160±48 days post-stroke), patients (n=77) had median mRS score of 3 [IQR, 2 - 3], decreasing to 2 [2 - 3] 30-days post-therapy (p<0.0001). Similarly, the proportion of patients with mRS score ≤2 increased from 46.8% at baseline to 66.2% at 30-days post-therapy (p=0.015). These findings were accounted for by the mRS score decreasing in 24 (31.2%) patients. Patients with a treatment-related mRS score improvement, compared to those without, had similar overall motor gains (change in total FM score, p=0.63). In exploratory analysis, improvement in several specific motor impairments, such as finger flexion and wrist circumduction, was significantly associated with higher likelihood of mRS decrease. CONCLUSIONS: Intensive arm motor therapy is associated with improved mRS in a substantial fraction (31.2%) of patients. Exploratory analysis suggests specific motor impairments that might underlie this finding and may be optimal targets for rehabilitation therapies that aim to reduce activities limitations. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients >90 days post-stroke with persistent arm motor deficits, intensive arm motor therapy improved mRS in a substantial fraction (31.2%) of patients.

4.
Neurosurgery ; 2021 Jan 19.
Artigo em Inglês | MEDLINE | ID: mdl-33469657

RESUMO

BACKGROUND: Intracranial atherosclerotic disease (ICAD) is one of the leading causes of stroke worldwide. Patients with ICAD who initially present with ischemia in border-zone areas and undergo intensive medical management (IMM) have the highest recurrence rates (37% at 1 yr) because of association with hemodynamic failure and poor collaterals. OBJECTIVE: To evaluate the effect of encephaloduroarteriosynagiosis (EDAS) on stroke recurrence in patients with ICAD and border-zone stroke (BDZS) at presentation. METHODS: A phase II clinical trial of EDAS revascularization for symptomatic ICAD failing medical management (EDAS Revascularization for Symptomatic Intracranial Atherosclerosis Steno-occlusive [ERSIAS]) was recently concluded. We analyze the outcomes of the subgroup of patients with BDZS at presentation treated with EDAS vs the previously reported Stenting versus Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) IMM subgroup with BDZS at presentation. RESULTS: Of 52 patients included in the ERSIAS trial, 35 presented with strokes at baseline, and 28 had a BDZ pattern, including 15 (54%) with exclusive BDZS and 13 (46%) with mixed patterns (BDZ plus other distribution). Three of the 28 (10.7%) had recurrent strokes up to a median follow-up of 24 months. The rate of recurrent stroke in ICAD patients with BDZS at presentation after EDAS was significantly lower than the rate reported in the SAMMPRIS IMM subgroup with BDZS at presentation (10.7% vs 37% P = .004, 95% CI = 0.037-0.27). CONCLUSION: ICAD patients with BDZS at presentation have lower rates of recurrent stroke after EDAS surgery than those reported with medical management in the SAMMPRIS trial. These results support further investigation of EDAS in a randomized clinical trial.

6.
Stroke ; : STROKEAHA119027900, 2020 Dec 04.
Artigo em Inglês | MEDLINE | ID: mdl-33272129

RESUMO

BACKGROUND AND PURPOSE: A survival advantage among individuals with higher body mass index (BMI) has been observed for diverse acute illnesses, including stroke, and termed the obesity paradox. However, prior ischemic stroke studies have generally tested only for linear rather than nonlinear relations between body mass and outcome, and few studies have investigated poststroke functional outcomes in addition to mortality. METHODS: We analyzed consecutive patients with acute ischemic stroke enrolled in a 60-center acute treatment trial, the NIH FAST-MAG acute stroke trial. Outcomes at 3 months analyzed were (1) death; (2) disability or death (modified Rankin Scale score, 2-6); and (3) low stroke-related quality of life (Stroke Impact Scale

7.
Stroke ; : STROKEAHA120030092, 2020 Dec 07.
Artigo em Inglês | MEDLINE | ID: mdl-33280549

RESUMO

BACKGROUND AND PURPOSE: Prediction of infarct extent among patients with acute ischemic stroke using computed tomography perfusion is defined by predefined discrete computed tomography perfusion thresholds. Our objective is to develop a threshold-free computed tomography perfusion-based machine learning (ML) model to predict follow-up infarct in patients with acute ischemic stroke. METHODS: Sixty-eight patients from the PRoveIT study (Measuring Collaterals With Multi-Phase CT Angiography in Patients With Ischemic Stroke) were used to derive a ML model using random forest to predict follow-up infarction voxel by voxel, and 137 patients from the HERMES study (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) were used to test the derived ML model. Average map, Tmax, cerebral blood flow, cerebral blood volume, and time variables including stroke onset-to-imaging and imaging-to-reperfusion time, were used as features to train the ML model. Spatial and volumetric agreement between the ML model predicted follow-up infarct and actual follow-up infarct were assessed. Relative cerebral blood flow <0.3 threshold using RAPID software and time-dependent Tmax thresholds were compared with the ML model. RESULTS: In the test cohort (137 patients), median follow-up infarct volume predicted by the ML model was 30.9 mL (interquartile range, 16.4-54.3 mL), compared with a median 29.6 mL (interquartile range, 11.1-70.9 mL) of actual follow-up infarct volume. The Pearson correlation coefficient between 2 measurements was 0.80 (95% CI, 0.74-0.86, P<0.001) while the volumetric difference was -3.2 mL (interquartile range, -16.7 to 6.1 mL). Volumetric difference with the ML model was smaller versus the relative cerebral blood flow <0.3 threshold and the time-dependent Tmax threshold (P<0.001). CONCLUSIONS: A ML using computed tomography perfusion data and time estimates follow-up infarction in patients with acute ischemic stroke better than current methods.

8.
Front Neurol ; 11: 594289, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33281733

RESUMO

In acute ischemic stroke, early recanalization of the occluded artery is crucial for best outcome to be achieved. Recanalization aims at restoring blood flow to the ischemic tissue (reperfusion) and is achieved with pharmacological thrombolytic drugs, endovascular thrombectomy (EVT) devices, or both. The introduction of modern endovascular devices has led to tremendous anatomical and clinical success with rates of substantial reperfusion exceeding 80% and proven clinical benefit in patients with anterior circulation large vessel occlusions (LVOs). However, not every successful reperfusion procedure leads to the desired clinical outcome. In fact, the rate of non-disabled outcome at 3 months with current EVT treatment is ~1 out of 4. A constraint upon better outcomes is that reperfusion, though resolving ischemic stress, may not restore the anatomic structures and metabolic functions of ischemic tissue to their baseline states. In fact, ischemia triggers a complex cascade of destructive mechanisms that can sometimes be exacerbated rather than alleviated by reperfusion therapy. Such reperfusion injury may cause infarct progression, intracranial hemorrhage, and unfavorable outcome. Therapeutic hypothermia has been shown to have a favorable impact on the molecular elaboration of ischemic injury, but systemic hypothermia is limited by slow speed of attaining target temperatures and clinical complications. A novel approach is endovascular delivery of hypothermia to cool the affected brain tissue selectively and rapidly with tight local temperature control, features not available with systemic hypothermia devices. In this perspective article, we discuss the possible benefits of adjunctive selective endovascular brain hypothermia during interventional stroke treatment.

9.
Circ Cardiovasc Qual Outcomes ; : CIRCOUTCOMES120007150, 2020 Dec 11.
Artigo em Inglês | MEDLINE | ID: mdl-33302714

RESUMO

Background The benefit of intravenous thrombolytic therapy for acute ischemic stroke is time dependent. To assist hospitals in providing faster thrombolytic treatment, the American Heart Association launched target: stroke quality initiative in January 2010 which disseminated feasible strategies to shorten door-to-needle times for thrombolytic therapy. This study aimed to examine whether target: stroke was associated with improved door-to-needle times and 1-year outcomes. Methods We analyzed Medicare beneficiaries aged ≥65 years receiving intravenous thrombolytic treatment for acute ischemic stroke at 1490 Get With The Guidelines-Stroke hospitals during January 2006 and December 2009 (preintervention, n=10 804) and January 2010 and December 2014 (postintervention, n=31 249). The median age was 80 years and 42.7% were male. Results The median door-to-needle times decreased from 80 minutes for the preintervention to 68 minutes for the postintervention (P<0.001). The proportion of patients receiving intravenous thrombolysis with door-to-needle times 45 minutes and 60 minutes increased from 9.6% and 24.8% for preintervention to 17.1% and 40.6% for postintervention, respectively (P<0.001). The annual rate of increase in the door-to-needle times of 60 minutes or less accelerated from 0.20% (95% CI, -0.43% to 0.83%) per each 4 quarters for preintervention to 5.68% (95% CI, 5.23%-6.13%) for postintervention (P<0.001) which was further confirmed in piecewise multivariable generalized estimating analysis (adjusted odds ratio, 1.27 [95% CI, 1.19-1.35]). Cox proportional hazards analysis, after adjusting for patient and hospital characteristics and within-hospital clustering, showed that target: stroke was associated with lower all-cause readmission (40.4% versus 44.1%; hazard ratio, 0.91 [95% CI, 0.88-0.95]), cardiovascular readmission (19.7% versus 22.9%; hazard ratio, 0.85 [95% CI, 0.80-0.89]), and composite of all-cause mortality or readmission (56.0% versus 58.4%; hazard ratio, 0.96 [95% CI, 0.93-1.00]). The risk decline in all-cause mortality dissipated after risk adjustment (adjusted hazard ratio, 0.98 [95% CI, 0.94-1.02]). Conclusions Target: stroke quality initiative was associated with faster thrombolytic treatment times for acute ischemic stroke and modestly lower 1-year all-cause and cardiovascular readmissions.

10.
J Neurointerv Surg ; 2020 Nov 20.
Artigo em Inglês | MEDLINE | ID: mdl-33219148

RESUMO

BACKGROUND: The benefit of endovascular thrombectomy for acute ischemic stroke with M2 segment middle cerebral artery occlusion remains controversial, with uncertainty and paucity of data specific to this population. OBJECTIVE: To compare outcomes between M1 and M2 occlusions in the Analysis of Revascularization in Ischemic Stroke with EmboTrap (ARISE II) trial. METHODS: We performed a prespecified analysis of the ARISE II trial with the primary outcome of 90-day modified Rankin Scale score of 0-2, which we termed good outcome. Secondary outcomes included reperfusion rates and major adverse events. The primary predictor was M2 occlusion, which we compared with M1 occlusion. RESULTS: We included 183 patients, of whom 126 (69%) had M1 occlusion and 57 (31%) had M2 occlusion. There was no difference in the reperfusion rates or adverse events between M2 and M1 occlusions. The rate of good outcome was not different in M2 versus M1 occlusions (70.2% vs 69.7%, p=0.946). In a logistic regression model adjusted for age, sex, and baseline National Institutes of Health Stroke Scale score, M2 occlusions did not have a significantly different odds of good outcome compared with M1 occlusions (OR 0.94, 95% CI 0.47 to 1.88, p=0.87). CONCLUSION: In ARISE II, M2 occlusions achieved a 70.2% rate of good outcome at 90 days, which is above published rates for untreated M2 occlusions and superior to prior reports of M2 occlusions treated with endovascular thrombectomy. We also report similar rates of good outcome, successful reperfusion, death, and other adverse events when comparing the M1 and M2 occlusions.

11.
J Stroke ; 22(3): 377-386, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33053953

RESUMO

BACKGROUND AND PURPOSE: Speedy decision-making is important for optimal outcomes from endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Figural decision aids facilitate rapid review of treatment benefits and harms, but have not yet been developed for late-presenting patients selected for EVT based on multimodal computed tomography or magnetic resonance imaging. METHODS: For combined pooled study-level randomized trial (DAWN and DEFUSE 3) data, as well as each trial singly, 100 person-icon arrays (Kuiper-Marshall personographs) were generated showing beneficial and adverse effects of EVT for patients with AIS and large vessel occlusion using automated (algorithmic) and expert-guided joint outcome table specification. RESULTS: Among imaging-selected patients 6 to 24 hours from last known well, for the full 7-category modified Rankin Scale (mRS), EVT had number needed to treat to benefit 1.9 (interquartile range [IQR], 1.9 to 2.1) and number needed to harm 40.0 (IQR, 29.2 to 58.3). Visual displays of treatment effects among 100 patients showed that, with EVT: 52 patients have better disability outcome, including 32 more achieving functional independence (mRS 0 to 2); three patients have worse disability outcome, including one more experiencing severe disability or death (mRS 5 to 6), mediated by symptomatic intracranial hemorrhage and infarct in new territory. Similar features were present in person-icon figures based on a 6-level mRS (levels 5 and 6 combined) rather than 7-level mRS, and based on the DAWN trial alone and DEFUSE 3 trial alone. CONCLUSIONS: Personograph visual decision aids are now available to rapidly educate patients, family, and healthcare providers regarding benefits and risks of EVT for late-presenting, imaging-selected AIS patients.

12.
Cardiovasc Ther ; 2020: 1494506, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33072188

RESUMO

Background: Cardiac adverse events are common among patients presenting with acute stroke and contribute to overall morbidity and mortality. Prophylactic measures for the reduction of cardiac adverse events in hospitalized stroke patients have not been well understood. We sought to investigate the effect of early initiation of high-dose intravenous magnesium sulfate on cardiac adverse events in stroke patients. Methods: This is a secondary analysis of the prehospital Field Administration of Stroke Therapy-Magnesium (FAST-MAG) randomized phase-3 clinical trial, conducted from 2005-2013. Consecutive patients with suspected acute stroke and a serum magnesium level within 72 hours of enrollment were selected. Twenty grams of magnesium sulfate or placebo was administered in the ambulance starting with a 15-minute loading dose intravenous infusion followed by a 24-hour maintenance infusion in the hospital. Results: Among 1126 patients included in the analysis of this study, 809 (71.8%) patients had ischemic stroke, 277 (24.6%) had hemorrhagic stroke, and 39 (3.5%) with stroke mimics. The mean age was 69.5 (SD13.4) and 42% were female. 565 (50.2%) received magnesium treatment, and 561 (49.8%) received placebo. 254 (22.6%) patients achieved the target, and 872 (77.4%) did not achieve the target, regardless of their treatment group. Among 1126 patients, 159 (14.1%) had at least one CAE. Treatment with magnesium was not associated with fewer cardiac adverse events. A multivariate binary logistic regression for predictors of CAEs showed a positive association of older age and frequency of CAEs (R = 1.04, 95% CI 1.03-1.06, p < 0.0001). Measures of early and 90-day outcomes did not differ significantly between the magnesium and placebo groups among patients who had CAEs. Conclusion: Treatment of acute stroke patients with magnesium did not result in a reduction in the number or severity of cardiac serious adverse events.


Assuntos
Cardiopatias/prevenção & controle , Hospitalização , Sulfato de Magnésio/administração & dosagem , Acidente Vascular Cerebral/tratamento farmacológico , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Esquema de Medicação , Feminino , Cardiopatias/diagnóstico , Cardiopatias/epidemiologia , Humanos , Incidência , Los Angeles/epidemiologia , Sulfato de Magnésio/efeitos adversos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Resultado do Tratamento
13.
Stroke ; 51(11): 3241-3249, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33081604

RESUMO

BACKGROUND AND PURPOSE: More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice has not been well-delineated. METHODS: Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institutes of Health Stroke Scale [NIHSS] score 0-5) from October 1, 2016, to December 31, 2017. Patient- and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death); in-hospital mortality; and radiological intracranial hemorrhage. RESULTS: Among 179 710 acute ischemic stroke admissions with recorded NIHSS during the 15-month study period, 103 765 (57.7%) had mild strokes (47.3% women; median age, 69 [interquartile range, 59-79] years; median NIHSS score of 2 [interquartile range, 1-4]). Considering reperfusion therapies among strokes with documented NIHSS, mild deficit hospitalizations accounted for 40.0% of IVT and 10.7% of mechanical thrombectomy procedures. Characteristics associated with IVT and with mechanical thrombectomy utilization were younger age, absence of diabetes, higher NIHSS score, larger/teaching hospital status, and Western US region. Excellent discharge outcome occurred in 48.2% of all mild strokes, and in multivariable analysis, was associated with younger age, male sex, White race, lower NIHSS score, absence of diabetes, heart failure, and kidney disease, and IVT use. IVT was associated with increased likelihood of excellent outcome (odds ratio, 1.90 [95% CI, 1.71-2.13], P<0.001) despite an increased risk of intracranial hemorrhage (odds ratio, 1.41 [95% CI, 1.09-1.83], P<0.001). CONCLUSIONS: In national US practice, more than one-half of acute ischemic stroke hospitalizations had mild deficits, accounting for 4 of every 10 IVT and 1 of every 10 mechanical thrombectomy treatments, and IVT use was associated with increased discharge to home despite increased intracranial hemorrhage.

14.
Int J Stroke ; : 1747493020967256, 2020 Oct 29.
Artigo em Inglês | MEDLINE | ID: mdl-33115382

RESUMO

BACKGROUND: Intracranial atherosclerotic disease (ICAD) is one of the most challenging stroke etiologies, with frequent recurrences despite optimized medical management. Encephaloduroarteriosynangiosis (EDAS) is an indirect revascularization method that produces extra-cranial collaterals to intracranial vessels. We present the results of a phase-II trial of EDAS in intracranial atherosclerotic disease patients. AIMS: To evaluate the feasibility, safety, and preliminary efficacy of EDAS in intracranial atherosclerotic disease patients. METHODS: ERSIAS was a prospective objective-performance-criterion trial of EDAS plus intensive medical management (IMM) in intracranial atherosclerotic disease (ICAD) patients failing medical treatment. Primary endpoint was any stroke/death within 30-days post-surgery or stroke in the territory of the qualifying artery beyond 30 days. The primary analysis compared event rates through one year with an objective-performance-criterion based on a 10% reduction from the 20% rate in the intensive medical management arm of the stenting versus aggressive medical management for preventing recurrent stroke in intracranial stenosis trial (SAMMPRIS) in patients with poor collaterals. Event rates through two years were compared with propensity-score-matched (PSM) medically treated patients from SAMMPRIS and the carotid occlusion surgery study (COSS). RESULTS: During a median follow-up of 24.5 months, 5 (9.6%) of 52 patients had a primary endpoint event. The primary endpoint rate at one year met the threshold for nonfutility and advancement to phase III (<10%). In the sensitivity analysis, primary endpoint event rate at two years was lower than in PSM controls, 9.6% versus 21.2% (p < 0.07). Overall, 86% of EDAS-plus-intensive medical management patients were functionally independent at last follow-up and 89% demonstrated neovascularization. There were two (3.8%) surgical complications and no intracranial hemorrhages. CONCLUSION: ERSIAS phase II provides evidence of safety and strong signals of efficacy of EDAS-plus-intensive medical management, supporting advancement to a seamless phase-IIb/III trial. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov.NCT01819597.

15.
Front Neurol ; 11: 524220, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33123069

RESUMO

Background and Purpose: Recent noninferiority clinical trials of novel endovascular thrombectomy devices for acute ischemic stroke have used substantial reperfusion as the primary outcome of achievement. Determining the minimal clinically important difference (MCID) is an essential step for the design of noninferiority clinical trials. Materials and Methods: We surveyed international neuro-interventionalist and noninterventional vascular neurologist investigators. The questionnaire included demographic characteristics, level of clinical experience, and their MCID clinical scenario-based judgment regarding the MCID for the outcome substantial reperfusion (thrombolysis in cerebral infarction score 2b-3) within 3 passes. Results: Survey responses were received from 58 of 200 experts. Among responders, 75.9% were neuro-interventionalists (most commonly interventional neuroradiologists and interventional neurologists, followed by endovascular neurosurgeons), and 24.1% were noninterventional vascular neurologists; 87.9% had been in practice for more than 5 years, and 67.3% devoted more than half of their practice to stroke care. Responder-nonresponder and continuum of resistance analysis indicated responders were representative of the full expert population. Among experts, the median MCID for substantial reperfusion was 3.1-5% (interquartile range 1.1-3% to 5.1-10%). MCID distributions did not differ among neuro-interventionalists and noninterventional vascular neurologists. Conclusions: Neuro-interventionl and noninterventional stroke experts judged that the minimal clinically important difference in comparing thrombectomy devices for achieving substantial reperfusion is 3.1-5%. This MCID, lower than noninferiority margins used in several recent clinical trials, can inform trial designs and clinical development.

16.
J Stroke Cerebrovasc Dis ; 29(12): 105292, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32992172

RESUMO

BACKGROUND: Positive pivotal trials followed by guideline endorsement can be a major driver of change in US national medical practice patterns. We therefore analyzed national trends in the use and outcomes of mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion before and after the 2015 publication of pivotal trials and the US guideline update. METHODS: We analyzed the National Inpatient Sample from 2012-2016. Ischemic stroke and mechanical thrombectomy patients were identified using ICD-9 and ICD-10. The primary efficacy outcome measure was discharge to home, which strongly correlates with mild degree of disability at discharge. Safety outcomes include in-hospital mortality and in-hospital medical complications. RESULTS: From 2012-2016, 2,394,550 discharges were recorded with a diagnosis of ischemic stroke, including 39,150 (1.6%) treated with mechanical thrombectomy. The number and proportion of stroke patients undergoing mechanical thrombectomy annually rose from 4,910/452,905 (1.1%) in 2012 to 11,860/509,215 (2.3%) in 2016. The largest annual increase occurred between 2014, when 6,460 stroke patients were treated with thrombectomy, and 2015, when 10,280 underwent thrombectomy. Comparing the pre (Q1 2012 - Q4 2014) and post (Q4 2015 - Q4 2016) RCT/Guideline epochs, in addition to increased thrombectomy rates, the proportion of thrombectomy patients who received IV-tPA decreased (46% to 24%, p<0.001). Rates of mild disability outcome increased from 16% to 20% (p<0.001), while mortality decreased from 15% to 13% (p=0.01). The odds of pulmonary embolism, urinary tract infection, and pneumonia decreased, while intracerebral hemorrhage, septicemia, deep venous thrombosis, shock, and cardiac arrest were unchanged. CONCLUSION: In the United States, thrombectomy treatment for acute ischemic stroke increased rapidly and substantially in frequency following publication of positive clinical trials and US guideline update in 2015, accompanied by improved functional outcomes and reduced peri-procedural mortality.

17.
J Stroke Cerebrovasc Dis ; 29(12): 105271, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32992192

RESUMO

BACKGROUND: MRI and CT modalities are both current standard-of-care options for initial imaging in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). MR provides greater lesion conspicuity and spatial resolution, but few series have demonstrated multimodal MR may be performed efficiently. METHODS: In a prospective comprehensive stroke center registry, we analyzed all anterior circulation LVO thrombectomy patients between 2012-2017 who: (1) arrived directly by EMS from the field, and (2) had initial NIHSS ≥6. Center imaging policy was multimodal MRI (including DWI/GRE/MRA w/wo PWI) as the initial evaluation in all patients without contraindications, and multimodal CT (including CT with CTA, w/wo CTP) in the remainder. RESULTS: Among 106 EMS-arriving endovascular thrombectomy patients, initial imaging was MRI 62.3%, CT in 37.7%. MRI and CT patients were similar in age (72.5 vs 71.3), severity (NIHSS 16.4 v 18.2), and medical history, though MRI patients had longer onset-to-door times. Overall, door-to-needle (DTN) and door-to-puncture (DTP) times did not differ among MR and CT patients, and were faster for both modalities in 2015-2017 versus 2012-2014. In the 2015-2017 period, for MR-imaged patients, the median DTN 42m (IQR 34-55) surpassed standard (60m) and advanced (45m) national targets and the median DTP 86m (IQR 71-106) surpassed the standard national target (90m). CONCLUSIONS: AIS-LVO patients can be evaluated by multimodal MR imaging with care speeds faster than national recommendations for door-to-needle and door-to-puncture times. With its more sensitive lesion identification and spatial resolution, MRI remains a highly viable primary imaging strategy in acute ischemic stroke patients, though further workflow efficiency improvements are desirable.

18.
Stroke ; 51(10): 3119-3123, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32921262

RESUMO

BACKGROUND AND PURPOSE: In patients with cryptogenic stroke and patent foramen ovale (PFO), the Risk of Paradoxical Embolism (RoPE) Score has been proposed as a method to estimate a patient-specific "PFO-attributable fraction"-the probability that a documented PFO is causally-related to the stroke, rather than an incidental finding. The objective of this research is to examine the relationship between this RoPE-estimated PFO-attributable fraction and the effect of closure in 3 randomized trials. METHODS: We pooled data from the CLOSURE-I (Evaluation of the STARFlex Septal Closure System in Patients With a Stroke and/or Transient Ischemic Attack due to Presumed Paradoxical Embolism through a Patent Foramen Ovale), RESPECT (Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment), and PC (Clinical Trial Comparing Percutaneous Closure of Patent Foramen Ovale [PFO] Using the Amplatzer PFO Occluder With Medical Treatment in Patients With Cryptogenic Embolism) trials. We examine the treatment effect of closure in high RoPE score (≥7) versus low RoPE score (<7) patients. We also estimated the relative risk reduction associated with PFO closure across each level of the RoPE score using Cox proportional hazard analysis. We estimated a patient-specific attributable fraction using a PC trial-compatible (9-point) RoPE equation (omitting the neuroradiology variable), as well as a 2-trial analysis using the original (10-point) RoPE equation. We examined the Pearson correlation between the estimated attributable fraction and the relative risk reduction across RoPE strata. RESULTS: In the low RoPE score group (<7, n=912), the rate of recurrent strokes per 100 person-years was 1.37 in the device arm versus 1.68 in the medical arm (hazard ratio, 0.82 [0.42-1.59] P=0.56) compared with 0.30 versus 1.03 (hazard ratio, 0.31 [0.11-0.85] P=0.02) in the high RoPE score group (≥7, n=1221); treatment-by-RoPE score group interaction, P=0.12. The RoPE score estimated attributable fraction anticipated the relative risk reduction across all levels of the RoPE score, in both the 3-trial (r=0.95, P<0.001) and 2-trial (r=0.92, P<0.001) analyses. CONCLUSIONS: The RoPE score estimated attributable fraction is highly correlated to the relative risk reduction of device versus medical therapy. This observation suggests the RoPE score identifies patients with cryptogenic stroke who are likely to have a PFO that is pathogenic rather than incidental.


Assuntos
Embolia Paradoxal/etiologia , Forame Oval Patente/complicações , Acidente Vascular Cerebral/complicações , Cateterismo Cardíaco , Forame Oval Patente/cirurgia , Humanos , Fatores de Risco , Prevenção Secundária , Resultado do Tratamento
19.
ESC Heart Fail ; 2020 Sep 13.
Artigo em Inglês | MEDLINE | ID: mdl-32924283

RESUMO

AIMS: Relative bleeding risks of different antithrombotic agents in heart failure (HF) patients is an important consideration in treatment decision making, making detailed comparative analysis desirable. The aim of this study was to conduct a network meta-analysis to investigate the major bleeding risk for individual novel oral anticoagulants (NOACs) vs. aspirin among patients with HF. METHODS AND RESULTS: We searched Pubmed, EMBASE, Cochrane Collaboration Central Register of Controlled Clinical Trials, and Clinicaltrials.gov from 1966 to November 2019 to identify relevant randomized clinical trials. Studies comparing individual NOACs vs. aspirin were analysed using direct study-level meta-analysis. Studies comparing aspirin to warfarin and NOACs to warfarin were then additionally added using network (direct and indirect) study-level meta-analysis. Primary endpoint was major bleeding. Final analysis included nine trials with 34 367 participants, including one direct comparison trial (apixaban vs. aspirin) and eight indirect comparison trials against the shared warfarin comparator (four aspirin trials and one trial each of apixaban, dabigatran, rivaroxaban, and edoxaban). For apixaban, network meta-analysis combing direct and indirect comparison showed that major bleeding risk might not be different between apixaban and aspirin (odds ratio, 1.18 [95% confidence interval, 0.38 to 3.65]) in HF patients. In contrast, indirect-comparison meta-analysis showed dabigatran, rivaroxaban, and edoxaban compared with aspirin might be associated with a higher risk of major bleeding in HF patients. CONCLUSIONS: In network meta-analysis, apixaban might be associated with a comparable risk of major bleeding compared with aspirin in patients with HF, while other NOACs might be associated with a higher risk. However, such results were not strongly convincing because of lack of direct comparison in an original trial and small sample size of trials and participants. A clinical trial directly comparing apixaban vs. aspirin in patients with HF and sinus rhythm may be worth undertaking.

20.
J Neurointerv Surg ; 2020 Sep 14.
Artigo em Inglês | MEDLINE | ID: mdl-32929047

RESUMO

BACKGROUND: Patient age and baseline Alberta Stroke Program Early CT score (ASPECTS) are both independent predictors of outcome in acute ischemic stroke patients treated with endovascular therapy (EVT). We assessed the combined effect of age and ASEPCTS on clinical outcome in acute ischemic stroke patients with LVO with and without EVT, and EVT treatment effect in different age/ASPECTS subgroups. METHODS: The HERMES collaboration pooled data of seven randomized controlled trials that tested the efficacy of EVT. Adjusted logistic regression was performed to test for multiplicative interaction of age and ASPECTS with the primary outcome (ordinal mRS) and secondary outcomes (mRS 0-2/0-1/0-3) in the EVT and control arms. Patients were then stratified by age (<75 vs ≥75 years) and ASPECTS (0-5/6-7/8-10), and adjusted effect-size estimates for the association of EVT were derived for the six age/ASPECTS subgroups. RESULTS: 1735 patients were included in the analysis. There was no multiplicative interaction between age and ASPECTS on clinical outcomes. In the exploratory subgroup analysis, we found a nominally negative point estimate for the association of EVT with clinical outcome in the ASPECTS 0-5/age ≥75, subgroup (acOR 0.36, 95% CI 0.07 to 1.89). The point estimate for moderate outcome (mRS0-3) nominally favored EVT (aOR 1.24, 95% CI 0.16 to 9.84). In all other subgroups, effect size-estimates consistently favored EVT. CONCLUSION: There was no multiplicative interaction of age and ASPECTS on clinical outcomes in EVT or control arm patients. Outcomes in patients ≥75 years with ASPECTS 0-5 were poor, irrespective of treatment. Further investigation to define the role of EVT and range of acceptable outcomes in this subgroup is warranted.

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