Characteristics and outcomes of stroke hospitalizations in patients with sickle cell disease and moyamoya syndrome

Endovascular thrombectomy versus intravenous tissue plasminogen activator for vertebrobasilar stroke treatment: insights from the national inpatient sample

Introduction

Approximately 20% of patients, who present with acute ischemic stroke are diagnosed with acute vertebrobasilar artery occlusion (VBAO), which is caused by an embolus or ruptured atherosclerotic plaque leading to the formation of an acute thrombus. The mortality rate of VBAO is extremely high without treatment, ranging from 80 to 95%, underscoring the urgent need for effective and timely treatment strategies. In this study, we examined the trends of hospitalizations for Endovascular Thrombectomy (EVT) or intravenous tissue plasminogen activator (IV-tPA) as interventions for VBAO, their outcomes, associated complications, and predictors of mortality in patients undergoing these procedures.

Methods

We utilized the National Inpatient Sample (NIS) database to extract data from the years 2016 to 2018, using ICD-10 diagnosis and procedure codes specific to occlusion or thrombosis of the vertebral artery or basilar artery, IV-tPA, and EVT.

Results

Between 2016 and 2018, a total of 37,310 patients were admitted with VBAO. Among these, tPA was administered in 2,530 admissions (6.8%), while EVT was performed in 2,330 admissions (6.2%). IV-tPA was more frequently used in the age groups of 65-84 years and, ≥85 years, whereas EVT was more commonly used in the age groups of 18-44 years and 45-64 years. There was no significant difference in usage between men and women. In large hospitals, EVT was more commonly used than IV-tPA (8.1% vs. 7%, p < 0.0001), while in small hospitals, IV-tPA usage was significantly higher (3.8% vs. 2%, p < 0.0001). The all-cause mortality rate was significantly higher in EVT admissions compared to IV-tPA admissions (16.8% vs. 8.1%, p < 0.0001). However, there was no significant difference in the mean length of stay (LOS) between the two modalities.

Conclusion

A trend of higher rates of EVT was observed in the younger age group (18-64 years) compared to the older age group, but no significant difference was noted based on sex. The all-cause mortality rate was found to be higher in the EVT group compared to the IV-tPA group. However, there was no significant difference in the length of hospital stay between the two groups.

Stroke-Related Outcomes in Moyamoya Disease Compared with Moyamoya Syndromes: A Propensity-Matched Analysis

OBJECTIVE

Moyamoya syndrome (MMS) is a subset of moyamoya disease (MMD) with a systemic comorbidity. Due to the lack of direct comparisons between various MMS subgroups and their MMD counterparts, we aimed to analyze differences in stroke-related outcomes between MMS subgroups and patients with MMD through propensity score matching (PSM).

METHODS

We analyzed the National Inpatient Sample (NIS) from 2011 to 2020 for patients with MMD and common MMS-related comorbidities: Down syndrome (DS), sickle-cell disease (SCD), and type 1 neurofibromatosis (NF1). PSM was performed to match patients of each MMS subgroup to patients with MMD only, controlling for stroke risk factors. Rates of ischemic strokes, hemorrhagic strokes, and transient ischemic attacks (TIAs) were evaluated after matching.

RESULTS

A total of 10,652 patients with a moyamoya diagnosis were identified: 7971 with MMD only, 2202 with MMS-SCD, 162 with MMS-NF1, and 317 with MMS-DS. PSM for MMD only and MMS-SCD resulted in 630 matched pairs. After matching, univariate analysis showed that patients with MMS-SCD had significantly lower rates of ischemic strokes (8.9% vs. 17.9%; P = 0.001), hemorrhagic strokes (5.1% vs. 8.1%; P = 0.031), and TIAs (2.2% vs. 4.6%; P = 0.020) than did patients with MMD only. For the MMS-DS subgroup, 92 matched pairs showed significantly lower rates of TIAs than did patients with MMD only (0% vs. 6.5%; P = 0.013). Comparing 54 matched pairs of patients with MMD only and patients with MMS-NF1 showed no significant differences in stroke-related outcomes.

CONCLUSIONS

Patients with MMS-SCD had significantly lower rates of acute ischemic stroke, hemorrhagic stroke, and TIA compared with patients with MMD only. Future research should consider the source of these differences in improving stroke prevention in patients with MMD.

Stroke Prevention and Treatment for Youth with Sickle Cell Anemia: Current Practice and Challenges and Promises for the Future

PURPOSE OF REVIEW

Sickle cell anemia (SCA) is an autosomal recessive inherited hemoglobinopathy that results in a high risk of stroke. SCA primarily affects an underserved minority population of children who are frequently not receiving effective, multi-disciplinary, preventative care. This article reviews primary and secondary stroke prevention and treatment for children with SCA for the general adult and pediatric neurologist, who may play an important role in providing critical neurologic evaluation and care to these children.

RECENT FINDINGS

Primary stroke prevention is efficacious at reducing ischemic stroke risk, but it is not consistently implemented into clinical practice in the United States, resulting in these children remaining at high risk. Acute symptomatic stroke management requires neurology involvement and emergent transfusion to limit ischemia. Furthermore, while chronic transfusion therapy is a proven secondary preventative modality for those with prior symptomatic or silent cerebral infarcts, it carries significant burden. Newer therapies (e.g., stem cell therapies and voxelotor) deserve further study as they may hold promise in reducing stroke risk and treatment burden. Effective primary and secondary stroke prevention and treatment remain a challenge. Informing and engaging neurology providers to recognize and provide critical neurologic evaluation and treatment has potential to close care gaps.

Stroke in sickle cell patients, epidemiology, pathophysiology, systemic and surgical treatment options and prevention strategies

Background

A hereditary haemoglobinopathy known as sickle cell disease (SCD) affects over 100 000 people in the United States severely. Cerebrovascular disease is a prominent consequence of SCD. By the age of 30, 53% of patients have silent cerebral infarcts (SCIs) (a stroke that occurs without any obvious symptoms because it damages a small part of the brain that isn't responsible for any essential functions), and by the age of 40, 3.8% have overt strokes.

Main body

The multidimensional burden of cerebrovascular illness in SCD is reviewed in detail in this article, which includes both clinical strokes and the frequently asymptomatic SCIs. The intricate pathophysiology of SCD and stroke is explored. With SCD, there are currently very few methods for preventing primary and secondary stroke; the most common ones are hydroxyurea and blood transfusion. Nevertheless, not enough research has been done on the possible contributions of anticoagulation and aspirin to strokes linked to SCD. Promising evidence is also highlighted in the study, suggesting that new drugs intended to treat SCD may be able to alleviate leg ulcers and renal impairment in addition to reducing unusually high transcranial Doppler flow velocity – a crucial component of cerebrovascular events. Given that these novel medications specifically target haemolysis and vaso‐occlusion, the two main causes of strokes in this population, more research is desperately needed to determine whether they are effective in avoiding strokes in people with SCD. The literature review also emphasizes how common healthcare inequities are and how they hinder advancements in SCD research and management in the United States.

Conclusion

To successfully address these inequities, the evaluation recommends more funding for both SCD management and research, as well as for patient and clinician education. This multimodal viewpoint highlights the intricate terrain of cerebrovascular problems associated with SCD and the urgent need for all‐encompassing and fair strategies to improve patient outcomes and advance research.

Prevalence of Stroke in Individuals with Sickle Cell Disease Pre- and during Hydroxyurea Uses: A Descriptive Cross-Sectional Study in Tanzania

Sickle cell disease (SCD) is an inherited blood disorder that leads to a variety of complications, including stroke. The use of hydroxyurea (HU) is reported to lessen the frequency and burden of stroke in SCD patients. However, less is known about the prevalence of stroke in SCD patients pre- and during the use of HU in sub-Saharan African (SSA) countries. Therefore, the study assessed stroke prevalence before and during uses of hydroxyurea among SCD patients in Tanzania. A hospital-based descriptive cross-sectional study was conducted at the sickle cell clinics in Dar es Salaam, Tanzania, from April 2023 to May 2023. A total of 228 participants were recruited, and data on demographic and clinical characteristics, HU use, and history of stroke were collected using a checklist from the respective patients' medical records and verbal communication with the patients or caregivers. Data analysis was done using SPSS software version 25, and findings are summarized using frequency and percentages. Out of 228 enrolled SCD patients, 124 (54.4%) were females, 109 (47.8%) were aged between 6 and 12 years, 226 (99.1%) were not married, 181 (79.4%) had primary education, and 209 (95%) were unemployed. The prevalence of stroke pre-HU use was 28 (12.3%) and 6 (2.6%) after starting using HU. Out of 6 with stroke after starting using HU, 3 (50%) had a history of stroke pre-HU uses. The study showed that the prevalence of stroke among SCD patients is significantly reduced after HU use. The findings suggest the need for stakeholders to implement measures to ensure eligible SCD patients are kept on HU.