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Huo S, Gao J, Lv Q, Xie M, Wang H, Zhang X, Xie Y, Wu M, Liu R, Liu X, Yuan K, Ye R. Trajectories of stroke severity and functional outcomes after endovascular treatment in ischemic stroke: A post hoc analysis of a randomized controlled trial. Clin Neurol Neurosurg 2024; 239:108248. [PMID: 38507987 DOI: 10.1016/j.clineuro.2024.108248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 02/26/2024] [Accepted: 03/15/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND The trajectory of early neurological changes in patients with acute ischemic stroke has been understudied. This study aimed to investigate the association between longitudinal trajectories of stroke severity and 90-day functional outcomes in patients with acute ischemic stroke receiving endovascular treatment. METHODS We enrolled patients from a prospective, multicenter, randomized controlled trial. The stroke severity was assessed with the National Institute of Health Stroke Scale at the pre-procedure, 24 hours, and seven days after the procedure. Group-based trajectory modeling (GBTM) was used to identify trajectories of stroke severity. Multivariable logistic regression was performed to explore the association between stroke severity markers and 90-day functional outcomes. RESULTS Of 218 enrolled patients, 127 (58.3%) had poor functional outcomes at 90 days. We identified three trajectories of stroke severity in the GBTM: stable symptom (38.1%), symptom deterioration (17.0%), and symptom improvement (44.9%). In multivariable analyses, trajectories of stroke severity were associated with an increased risk of poor functional outcomes (symptom improvement versus symptom deterioration: odds ratio, 0.007; 95% confidence interval, 0.001-0.040; P <0.001). Reclassification indexes revealed that trajectories of stroke severity would increase the predictive ability for poor functional outcomes at 90 days. CONCLUSION After endovascular treatment, patients would follow one of three distinct trajectories of stroke severity. Symptom deterioration trajectory was associated with an increased risk of poor functional outcomes at 90 days. TRIAL REGISTRATION NUMBER NCT04973332.
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Affiliation(s)
- Shuxian Huo
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China
| | - Jie Gao
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China
| | - Qiushi Lv
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China
| | - Mengdi Xie
- Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
| | - Huaiming Wang
- Department of Neurology, The 80th Group Army Hospital of The People's Liberation Army, Weifang, Shandong 261021, China
| | - Xiaohao Zhang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210000, China
| | - Yi Xie
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China
| | - Min Wu
- Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
| | - Rui Liu
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China; Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
| | - Xinfeng Liu
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China; Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
| | - Kang Yuan
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China.
| | - Ruidong Ye
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China; Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
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Zeinhom MG, Khalil MFE, Kamel IFM, Kohail AM, Ahmed SR, Elbassiouny A, Shuaib A, Al-Nozha OM. Predictors of the unfavorable outcomes in acute ischemic stroke patients treated with alteplase, a multi-center randomized trial. Sci Rep 2024; 14:5960. [PMID: 38472241 PMCID: PMC10933394 DOI: 10.1038/s41598-024-56067-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/01/2024] [Indexed: 03/14/2024] Open
Abstract
Worldwide, stroke is a leading cause of long-term disability in adults. Alteplase is the only approved treatment for acute ischemic stroke (AIS) and results in an improvement in a third of treated patients. We evaluated the post-stroke unfavourable outcome predictors in alteplase-treated patients from Egypt and Saudi Arabia. We assessed the effect of different risk factors on AIS outcomes after alteplase in Egypt and Saudi Arabia. Our study included 592 AIS alteplase-treated patients. The relationship between risk factors, clinical presentation, and imaging features was evaluated to predict factors associated with poor outcomes. An mRS score of three or more was used to define poor outcomes. Poor outcome was seen in 136 patients (23%), and Patients with unfavourable effects had significantly higher admission hyperglycaemia, a higher percentage of diabetes mellitus, cardioembolic stroke, and a lower percentage of small vessel stroke. Patients with higher baseline NIHSS score (OR 1.39; 95% CI 1.12-1.71; P = 0.003), admission hyperglycaemia (OR 13.12; 95% CI 3.37-51.1; P < 0.001), and post-alteplase intracerebral haemorrhage (OR 7.41; 95% CI 1.69-32.43; P = 0.008) independently predicted unfavourable outcomes at three months. In AIS patients treated with alteplase, similar to reports from other regions, in patients from Egypt and Saudi Arabia also reveal that higher NIHSS, higher serum blood sugar, and post-alteplase intracerebral haemorrhage were the predictors of unfavourable outcomes three months after ischemic stroke.Trial registration: (clinicaltrials.gov NCT06058884), retrospectively registered on 28/09/2023.
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Affiliation(s)
- Mohamed G Zeinhom
- Neurology Department, Faculty of Medicine, Kafr El-Sheikh University, Elgeish Street, Kafr El-Sheikh, Egypt.
| | | | | | - Ahmed Mohamed Kohail
- Neurology Department, Faculty of Medicine, Al-Azhar University, ELmokhaim St., Cairo, Egypt
| | - Sherihan Rezk Ahmed
- Neurology Department, Faculty of Medicine, Kafr El-Sheikh University, Elgeish Street, Kafr El-Sheikh, Egypt
| | - Ahmed Elbassiouny
- Neurology Department, Faculty of Medicine, Ain Shams University, ELabbasia St., Cairo, Egypt
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Clinical Sciences Building, Edmonton, AB, T6G 2R3, Canada
| | - Omar M Al-Nozha
- Medicine Department, College of Medicine, Taibah University, Janadah Bin Umayyah Rd., Tayba, Madinah, Saudi Arabia
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Hagberg G, Ihle-Hansen H, Abzhandadze T, Reinholdsson M, Hansen HI, Sunnerhagen KS. Prognostic value of acute National Institutes of Health Stroke Scale Items on disability: a registry study of first-ever stroke in the western part of Sweden. BMJ Open 2023; 13:e080007. [PMID: 38110379 DOI: 10.1136/bmjopen-2023-080007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVES We aimed to study how the individual items of the National Institutes of Health Stroke Scale (NIHSS) at admission predict functional independence 3 months post-stroke in patients with first-ever stroke. SETTING This registry-based study used data from two Swedish stroke registers (Riksstroke, the mandatory national quality register for stroke care in Sweden, and Väststroke, a local quality stroke register in Gothenburg). PARTICIPANTS This study included patients with first-ever acute stroke admitted from November 2014 to August 2018, with available NIHSS at admission and modified Rankin Scale (mRS) at 3-month follow-up. PRIMARY OUTCOME The primary outcome variable was mRS≤1 (defined as an excellent outcome) at 3-month follow-up. RESULTS We included 1471 patients, mean age was 72 (± 14.5) years, 48% were female, and 66% had mild strokes (NIHSS≤3). In adjusted binary logistic regression analysis, the NIHSS items impaired right motor arm and leg, and impairment in visual field, reduced the odds of an excellent outcome at 3 months ((OR 0.60 (95% CI 0.37 to 0.98), OR 0.60 (95% CI 0.37 to 0.97), and OR 0.65 (95% CI 0.45 to 0.94)). When exploring the effect size of associations between NIHSS items and mRS≤1 p, orientation, language and right leg motor had the largest yet small association. CONCLUSIONS Stroke patients with scores on the NIHSS items right motor symptoms or visual field at admission are less likely to have an excellent outcome at 3 months. Clinicians should consider the NIHSS items affected, not only the total NIHSS score, both in treatment guidance and prognostics.
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Affiliation(s)
- Guri Hagberg
- Oslo Stroke Unit, Neurological Department, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Neuroscience and Physiology, Section for Clinical Neuroscience and Rehabilitation, Gothenburg University, Goteborg, Sweden
| | - Haakon Ihle-Hansen
- Bærum Hospital- Vestre Viken Hospital Trust, Department of Medicine, Drammen, Norway
| | - Tamar Abzhandadze
- Institute of Neuroscience and Physiology, Section for Clinical Neuroscience and Rehabilitation, Gothenburg University, Goteborg, Sweden
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Malin Reinholdsson
- Institute of Neuroscience and Physiology, Section for Clinical Neuroscience and Rehabilitation, Gothenburg University, Goteborg, Sweden
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Hege Ihle Hansen
- Oslo Stroke Unit, Neurological Department, Oslo University Hospital, Ullevål, Oslo, Norway
- Bærum Hospital- Vestre Viken Hospital Trust, Department of Medicine, Drammen, Norway
| | - Katharina S Sunnerhagen
- Institute of Neuroscience and Physiology, Section for Clinical Neuroscience and Rehabilitation, Gothenburg University, Goteborg, Sweden
- Neurocare, Sahlgrenska University Hospital, Goteborg, Sweden
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Aref HM, El-Khawas H, Elbassiouny A, Shokri HM, Zeinhom MG, Roushdy TM. A randomized pilot study of the efficacy and safety of loading ticagrelor in acute ischemic stroke. Neurol Sci 2023; 44:765-771. [PMID: 36446950 PMCID: PMC9842543 DOI: 10.1007/s10072-022-06525-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/20/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Ticagrelor is one of the most recent antiplatelet drugs to be approved to treat ischemic heart disease. Its efficacy may exceed aspirin in improving clinical outcomes in patients with acute ischemic stroke who are ineligible for rt-PA. OBJECTIVES We evaluated the safety regarding hemorrhagic complications (as a primary endpoint) and the efficacy (as a secondary endpoint) of a 180-mg loading dose of ticagrelor given within 9 h from the onset of the first-ever non-cardioembolic ischemic stroke. METHODS We conducted our study on patients aged 18-75 years who presented with their first clinically manifested non-cardioembolic ischemic stroke and were recruited from the emergency department OF Kafr El-Sheik University Hospitals, Egypt. Eligible patients randomly received ticagrelor or aspirin loading and maintenance doses. Screening, randomization, and initiation of treatment all occurred within the first 9 h of stroke onset. RESULTS Eighty-five patients received ticagrelor, and 84 received aspirin. Patients who received ticagrelor had a better clinical outcome in terms of NIHSS improvement at 2 days and 1 week of discharge and a favorable mRS score after 1 week of discharge and at 90-day follow-up. There was no significant difference between the two groups regarding hemorrhagic adverse effects. CONCLUSION This pilot study found that ticagrelor had a better clinical outcome than aspirin based on NIHSS and mRS in acute ischemic stroke patients who received it within 9 h from symptom onset and had a shorter hospital stay duration. Ticagrelor was non-inferior to aspirin regarding hemorrhagic complications. TRIAL REGISTRATION We registered our trial on ClinicalTrials.gov, named after "ticagrelor versus aspirin in ischemic stroke," and with a clinical trial number (NCT03884530)-March 21, 2019.
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Affiliation(s)
- Hany M. Aref
- grid.7269.a0000 0004 0621 1570Neurology Department, Faculty of Medicine, Ain Shams University, Al Khalifa Elmamon St., Cairo, Egypt
| | - Hala El-Khawas
- grid.7269.a0000 0004 0621 1570Neurology Department, Faculty of Medicine, Ain Shams University, Al Khalifa Elmamon St., Cairo, Egypt
| | - Ahmed Elbassiouny
- grid.7269.a0000 0004 0621 1570Neurology Department, Faculty of Medicine, Ain Shams University, Al Khalifa Elmamon St., Cairo, Egypt
| | - Hossam M. Shokri
- grid.7269.a0000 0004 0621 1570Neurology Department, Faculty of Medicine, Ain Shams University, Al Khalifa Elmamon St., Cairo, Egypt
| | - Mohamed G. Zeinhom
- grid.411978.20000 0004 0578 3577Neurology Department, Faculty of Medicine, Kafr El-Sheikh University, Elgeish St., Kafr El-Sheikh, Egypt
| | - Tamer M. Roushdy
- grid.7269.a0000 0004 0621 1570Neurology Department, Faculty of Medicine, Ain Shams University, Al Khalifa Elmamon St., Cairo, Egypt
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Chen J, Liu S, Wu M, Dai L, Wang J, Xie W, Peng Y, Mu J, Yang S, Ran J, Zhang J, Niu W, Zheng J, Wu J, Yuan G. Twenty-four-hour National Institute of Health Stroke Scale predicts short- and long-term outcomes of basilar artery occlusion after endovascular treatment. Front Aging Neurosci 2022; 14:941034. [PMID: 36337700 PMCID: PMC9632169 DOI: 10.3389/fnagi.2022.941034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 09/28/2022] [Indexed: 11/18/2022] Open
Abstract
Background The present study aimed to evaluate the prognostic value of the 24-h National Institute of Health Stroke Scale (NIHSS) for short- and long-term outcomes of patients with basilar artery occlusion (BAO) after endovascular treatment (EVT) in daily clinical routine. Methods Patients with EVT for acute basilar artery occlusion study registry with the 24-h NIHSS, and clinical outcomes documented at 90 days and 1 year were included. The NIHSS admission, 24-h NIHSS, NIHSS delta, and NIHSS percentage change, binary definitions of early neurological improvement [ENI; improvement of 4/(common ENI)/8 (major ENI)/10 (dramatic ENI)] NIHSS points were compared to predict the favorable outcomes and mortality at 90 days and 1 year. The primary outcome was defined as favorable if the modified Rankin Scale (mRS) score was 0–3 at 90 days. Results Of the 644 patients treated with EVT, the 24-h NIHSS had the highest discriminative ability for favorable outcome prediction [receiver operator characteristic (ROC)NIHSS 24 h area under the curve (AUC): 0.92 (0.90–0.94)] at 90 days and 1 year [(ROCNIHSS 24 h AUC: 0.91 (0.89–0.94)] in comparison to the NIHSS score at admission [ROCNIHSS admission AUC at 90 days: 0.73 (0.69–0.77); 1 year: 0.74 (0.70–0.78)], NIHSS delta [ROCΔ NIHSS AUC at 90 days: 0.84 (0.81–0.87); 1 year: 0.81 (0.77–0.84)], and NIHSS percentage change [ROC%change AUC at 90 days: 0.85 (0.82–0.89); 1 year: 0.82 (0.78–0.86)]. Conclusion The 24-h NIHSS with a threshold of ≤23 points was the best surrogate for short- and long-term outcomes after EVT for BAO in the clinical routine.
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Affiliation(s)
- Jing Chen
- Department of Neurology, Baoji Central Hospital, Baoji, Shanxi, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Mingchao Wu
- Department of Neurology, Jingdezhen No.1 People’s Hospital, Jingdezhen, Jiangxi, China
| | - Ling Dai
- Department of Neurology, Luxian People’s Hospital, Luzhou, Sichuan, China
| | - Jie Wang
- Department of Neurology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Weihua Xie
- Department of Neurology, People’s Hospital of Mengzi, Mengzi, Yunnan, China
| | - Yuqi Peng
- Center of Brain, Sichuan Science City Hospital, Mianyang, China
| | - Jinlin Mu
- Department of Neurology, Traditional Chinese Medicine Hospital of Nanjiang, Bazhong, Sichuan, China
| | - Shunyu Yang
- Department of Neurology, The First People’s Hospital of Yunnan, Kunming, Yunnan, China
| | - Jinbo Ran
- Department of Neurology, People’s Hospital of Dejiang, Tongren, Guizhou, China
| | - Jian Zhang
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Wenshu Niu
- Department of Neurology, The 988th Hospital of the People’s Liberation Army, Zhengzhou, Henan, China
| | - Jingbang Zheng
- Department of Neurology, Chongqing Sanbo Changan Hospital, Chongqing, China
| | - Junxiong Wu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, Hunan, China
- *Correspondence: Guangxiong Yuan,
| | - Guangxiong Yuan
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, Hunan, China
- Junxiong Wu,
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Kniep H, Bechstein M, Broocks G, Brekenfeld C, Flottmann F, van Horn N, Geest V, Faizy TD, Deb‐Chatterji M, Alegiani A, Thomalla G, Gellißen S, Fiehler J, Hanning U, Meyer L. Early Surrogates of Outcome after Thrombectomy in Posterior Circulation Stroke. Eur J Neurol 2022; 29:3296-3306. [DOI: 10.1111/ene.15519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/30/2022] [Accepted: 08/01/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Vincent Geest
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Tobias D. Faizy
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | | | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona Hamburg Germany
| | - Götz Thomalla
- Department of Neurology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
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Kniep H, Meyer L, Bechstein M, Broocks G, Guerreiro H, van Horn N, Brekenfeld C, Flottmann F, Deb-Chatterji M, Alegiani A, Thomalla G, Hanning U, Fiehler J, Gellißen S. How Much of the Thrombectomy Related Improvement in Functional Outcome Is Already Apparent at 24 Hours and at Hospital Discharge? Stroke 2022; 53:2828-2837. [PMID: 35549377 DOI: 10.1161/strokeaha.121.037888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early neurological status has been described as predictor of functional outcome in patients with anterior circulation stroke after mechanical thrombectomy. It remains unclear to what proportion the improvement of functional outcome at day 90 is already apparent at 24 hours and at hospital discharge and how later factors impact outcome. METHODS All patients enrolled in the German Stroke Registry (June 2015-December 2019) with anterior circulation stroke and availability of baseline data and neurological status were included. A mediation analysis was conducted to investigate the effect of successful recanalization (Thrombolysis in Cerebral Infarction scale score ≥2b) on good functional outcome (modified Rankin Scale score ≤2 at day 90) with mediation through neurological status (National Institutes of Health Stroke Scale [NIHSS] at 24 hours and at hospital discharge). RESULTS Three thousand fifty-seven patients fulfilled the inclusion criteria, thereof 2589 (85%) with successful recanalization and 1180 (39%) with good functional outcome. In a multivariate logistic regression analysis, probability of good outcome was significantly associated with age (odds ratio [95% CI], 0.95 [0.94-0.96]), prestroke modified Rankin Scale (0.48 [0.42-0.55]), admission-NIHSS (0.96 [0.94-0.98]), 24-hour NIHSS (0.83 [0.81-0.84]), diabetes (0.56 [0.43-0.72]), proximal middle cerebral artery occlusions (0.78 [0.62-0.97]), passes (0.88 [0.82-0.95]), Alberta Stroke Program Early CT Score (1.07 [1.00-1.14]), successful recanalization (2.39 [1.68-3.43]), intracerebral hemorrhage (0.51 [0.35-0.73]), and recurrent strokes (0.54 [0.32-0.92]). Mediation analysis showed a 20 percentage points (95% CI' 17-24 percentage points) increase of probability of good functional outcome after successful recanalization. Fifty-four percent (95% CI' 44%-66%) of the improvement in functional outcome was explained by 24-hour NIHSS and 75% (95% CI' 62%-90%) by NIHSS at hospital discharge. CONCLUSIONS Fifty-four percent of the improvement in functional outcome after successful recanalization is apparent in NIHSS at 24 hours, 75% in NIHSS at hospital discharge. Other unknown factors not apparent in NIHSS at the 2 time points investigated account for the remaining effect on long term outcome, suggesting, among others, clinical relevance of delayed neurological improvement and deterioration. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03356392.
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Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Helena Guerreiro
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany. (M.D.-C., A.A., G.T.)
| | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany (A.A)
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany. (M.D.-C., A.A., G.T.)
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
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Padrick MM, Brown W, Lyden PD. Intravenous Thrombolysis. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00053-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Adams HP. Clinical Scales to Assess Patients With Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Combined Perfusion and Permeability Imaging Reveals Different Pathophysiologic Tissue Responses After Successful Thrombectomy. Transl Stroke Res 2021; 12:799-807. [PMID: 33432454 PMCID: PMC8421283 DOI: 10.1007/s12975-020-00885-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 12/10/2020] [Accepted: 12/28/2020] [Indexed: 12/19/2022]
Abstract
Despite successful recanalization of large-vessel occlusions in acute ischemic stroke, individual patients profit to a varying degree. Dynamic susceptibility-weighted perfusion and dynamic T1-weighted contrast-enhanced blood-brain barrier permeability imaging may help to determine secondary stroke injury and predict clinical outcome. We prospectively performed perfusion and permeability imaging in 38 patients within 24 h after successful mechanical thrombectomy of an occlusion of the middle cerebral artery M1 segment. Perfusion alterations were evaluated on cerebral blood flow maps, blood-brain barrier disruption (BBBD) visually and quantitatively on ktrans maps and hemorrhagic transformation on susceptibility-weighted images. Visual BBBD within the DWI lesion corresponded to a median ktrans elevation (IQR) of 0.77 (0.41–1.4) min−1 and was found in all 7 cases of hypoperfusion (100%), in 10 of 16 cases of hyperperfusion (63%), and in only three of 13 cases with unaffected perfusion (23%). BBBD was significantly associated with hemorrhagic transformation (p < 0.001). While BBBD alone was not a predictor of clinical outcome at 3 months (positive predictive value (PPV) = 0.8 [0.56–0.94]), hypoperfusion occurred more often in patients with unfavorable clinical outcome (PPV = 0.43 [0.10–0.82]) compared to hyperperfusion (PPV = 0.93 [0.68–1.0]) or unaffected perfusion (PPV = 1.0 [0.75–1.0]). We show that combined perfusion and permeability imaging reveals distinct infarct signatures after recanalization, indicating the severity of prior ischemic damage. It assists in predicting clinical outcome and may identify patients at risk of stroke progression.
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Deeds SI, Barreto A, Elm J, Derdeyn CP, Berry S, Khatri P, Moy C, Janis S, Broderick J, Grotta J, Adeoye O. The multiarm optimization of stroke thrombolysis phase 3 acute stroke randomized clinical trial: Rationale and methods. Int J Stroke 2020; 16:873-880. [PMID: 33297893 DOI: 10.1177/1747493020978345] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Intravenous recombinant tissue plasminogen activator is the only proven effective medication for the treatment of acute ischemic stroke. Two approaches that may augment recombinant tissue plasminogen activator thrombolysis and prevent arterial reocclusion are direct thrombin inhibition with argatroban and inhibition of the glycoprotein 2b/3a receptor with eptifibatide. AIM The multi-arm optimization of stroke thrombolysis trial aims to determine the safety and efficacy of intravenous therapy with argatroban or eptifibatide as compared with placebo in acute ischemic stroke patients treated with intravenous recombinant tissue plasminogen activator within 3 h of symptom onset. SAMPLE SIZE ESTIMATE A maximum of 1200 randomized subjects to test the superiority of argatroban or eptifibatide to placebo in improving 90-day modified Rankin scores. METHODS AND DESIGN Multiarm optimization of stroke thrombolysis is a multicenter, multiarm, adaptive, single blind, randomized controlled phase 3 clinical trial conducted within the National Institutes of Health StrokeNet clinical trial network. Patients treated with 0.9 mg/kg intravenous recombinant tissue plasminogen activator within 3 h of stroke symptom onset are randomized to receive intravenous argatroban (100 µg/kg bolus followed by 3 µg/kg/min for 12 h), intravenous eptifibatide (135 µg/kg bolus followed by 0.75 µg/kg/min infusion for 2 h) or IV placebo. Patients may receive endovascular thrombectomy per usual care. STUDY OUTCOMES The primary efficacy outcome is improved modified Rankin score assessed at 90 days post-randomization. DISCUSSION Multiarm optimization of stroke thrombolysis is an innovative and collaborative project that is the culmination of many years of dedicated efforts to improve outcomes for stroke patients.
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Affiliation(s)
- S Iris Deeds
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Andrew Barreto
- Department of Neurology, University of Texas Health Science Center, Houston, TX, USA
| | - Jordan Elm
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Colin P Derdeyn
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH, USA
| | - Claudia Moy
- 35046National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Scott Janis
- 35046National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Joseph Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH, USA.,UC Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - James Grotta
- Memorial Hermann Hospital - Texas Medical Center, Houston, TX, USA
| | - Opeolu Adeoye
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
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Meyer L, Broocks G, Bechstein M, Flottmann F, Leischner H, Brekenfeld C, Schön G, Deb-Chatterji M, Alegiani A, Thomalla G, Fiehler J, Kniep H, Hanning U. Early clinical surrogates for outcome prediction after stroke thrombectomy in daily clinical practice. J Neurol Neurosurg Psychiatry 2020; 91:1055-1059. [PMID: 32934109 DOI: 10.1136/jnnp-2020-323742] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE To investigate early clinical surrogates for long-term independency of patients treated with thrombectomy for large vessel occlusion stroke in daily clinical routine. METHODS All patients with anterior circulation stroke enrolled in the German Stroke Registry-Endovascular Treatment from 07/2015 to 04/2018 were analysed. National Institute of Health Stroke Scale (NIHSS) on admission, NIHSS percentage change, NIHSS delta and NIHSS at 24 hours as well as existing binary definitions of early neurological improvement (ENI; improvement of 8 (major ENI)/10 (dramatic ENI) NIHSS points or reaching 0/1 were compared for predicting functional outcome at 90 days using the modified Rankin Scale (mRS). Excellent and favourable outcome were defined as 0-1 and 0-2, respectively. RESULTS Among 2262 endovasculary treated patients with acute ischaemic anterior circulation stroke, NIHSS at 24 hours had the highest discriminative ability to predict excellent (receiver operator characteristics (ROC)NIHSS 24 hours area under the curve (AUC) 0.86 (0.84-0.88)) and favourable long-term functional outcome (ROCNIHSS 24 hours AUC 0.86 (0.85-0.88)) in comparison to NIHSS percentage change (ROC% change AUC mRS ≤1: 0.81 (0.78-0.83) mRS ≤2: 0.81 (0.79-0.83)), NIHSS delta change (ROCΔ change AUC mRS ≤1: 0.74 (0.72-0.77), mRS ≤2: 0.77 (0.74-0.79)) and NIHSS admission (ROCAdm AUC mRS ≤1: 0.70 (0.68-0.73), mRS ≤2: 0.67 (0.68-0.71)). Advanced age was the only independent predictor (adjusted OR 1.05, 95% CI 1.03 to 1.07, p<0.001) for turning the outcome prognosis from favourable (mRS ≤2) to poor (mRS ≥4) at 90 days. CONCLUSION The NIHSS at 24 hours postintervention with a threshold of ≤8 points serves best as a surrogate for long-term functional outcome after thrombectomy for anterior circulation stroke in daily clinical practice. Only advanced age significantly decreases its predictive value.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Lv S, Song Y, Zhang FL, Yan XL, Chen J, Gao L, Guo ZN, Yang Y. Early prediction of the 3-month outcome for individual acute ischemic stroke patients who received intravenous thrombolysis using the N2H3 nomogram model. Ther Adv Neurol Disord 2020; 13:1756286420953054. [PMID: 35173805 PMCID: PMC8842152 DOI: 10.1177/1756286420953054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/31/2020] [Indexed: 01/01/2023] Open
Abstract
Background: The aim of this study was to establish a nomogram model for individualized
early prediction of the 3-month prognosis in patients with acute ischemic
stroke (AIS) who were treated with intravenous recombinant tissue
plasminogen activator (rt-PA) thrombolysis. Methods: A total of 691 patients were included in this study; 564 patients were
included in the training cohort, while 127 patients were included in the
test cohort. The main outcome measure was a 3-month unfavorable outcome
(modified Rankin Scale 3–6). To construct the nomogram model, stepwise
logistic regression analysis was applied to select the significant
predictors of the outcome. The discriminative performance of the model was
assessed by calculating the area under the receiver operating characteristic
curve (AUC-ROC). A decision curve analysis was used to evaluate prognostic
value of the model. Results: The initial National Institutes of Health Stroke Scale [NIHSS, odds ratio
(OR), 1.35; 95% confidence interval (CI), 1.28–1.44;
p < 0.001], delta NIHSS (changes in the NIHSS score from
baseline to 24 h, OR, 0.75; 95% CI, 0.70–0.79;
p < 0.001), hypertension (OR, 2.07; 95% CI, 1.32–3.31;
p = 0.002), hyperhomocysteinemia (Hhcy, OR, 2.18; 95%
CI, 1.20–4.11; p = 0.013), and the ratio of high-density
lipoprotein cholesterol (HDL-C) to low-density lipoprotein cholesterol
(LDL-C) (HDL-C/LDL-C, OR, 3.29; 95% CI, 1.00–10.89;
p = 0.049) (N2H3) were found to be independent predictors
of a 3-month unfavorable outcome from multivariate logistic regression
analysis and were incorporated in the N2H3 nomogram model. The AUC-ROC of
the training cohort was 0.872 (95% CI, 0.841–0.902), and the AUC-ROC of the
test cohort was 0.900 (95% CI, 0.848–0.953). Conclusion: The study presented the N2H3 nomogram model, with initial NIHSS score, delta
NIHSS, hypertension, Hhcy, and HDL-C/LDL-C as predictors. It therefore
provides an individualized early prediction of the 3-month unfavorable
outcome in AIS patients treated with intravenous rt-PA thrombolysis.
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Affiliation(s)
- Shan Lv
- Stroke Center & Clinical Trial and Research Center for Stroke, Department of Neurology, the First Hospital of Jilin University, Changchun, China
- China National Comprehensive Stroke Center, Changchun, China
- Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
- Jilin Provincial Key Laboratory, the First Hospital of Jilin University, Changchun, China
| | - Yu Song
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fu-Liang Zhang
- Stroke Center & Clinical Trial and Research Center for Stroke, Department of Neurology, the First Hospital of Jilin University, Changchun, China
- China National Comprehensive Stroke Center, Changchun, China
- Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
- Jilin Provincial Key Laboratory, the First Hospital of Jilin University, Changchun, China
| | - Xiu-Li Yan
- Stroke Center & Clinical Trial and Research Center for Stroke, Department of Neurology, the First Hospital of Jilin University, Changchun, China
- China National Comprehensive Stroke Center, Changchun, China
- Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
- Jilin Provincial Key Laboratory, the First Hospital of Jilin University, Changchun, China
| | - Jie Chen
- Stroke Center & Clinical Trial and Research Center for Stroke, Department of Neurology, the First Hospital of Jilin University, Changchun, China
- China National Comprehensive Stroke Center, Changchun, China
- Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
- Jilin Provincial Key Laboratory, the First Hospital of Jilin University, Changchun, China
| | - Liang Gao
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhen-Ni Guo
- China National Comprehensive Stroke Center & Clinical Trial and Research Center for Stroke, Department of Neurology, Jilin Provincial Key Laboratory, the First Hospital of Jilin University, No. 1 Xinmin Street, Changchun 130021, China
- Clinial Trial and Research Center for Stroke, Department of Neurology, the First Hospital of Jilin University, Changchun, China
- Jilin Provincial Key Laboratory, the First Hospital of Jilin University, Changchun, China
| | - Yi Yang
- China National Comprehensive Stroke Center & Clinical Trial and Research Center for Stroke, Department of Neurology, the First Hospital of Jilin University, No. 1 Xinmin Street, Changchun 130021, China
- Clinial Trial and Research Center for Stroke, Department of Neurology, the First Hospital of Jilin University, Changchun, China
- Jilin Provincial Key Laboratory, the First Hospital of Jilin University, Changchun, China
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Bayona H, Ropero B, Salazar AJ, Pérez JC, Granja MF, Martínez CF, Useche JN. Comprehensive Telestroke Network to Optimize Health Care Delivery for Cerebrovascular Diseases: Algorithm Development. J Med Internet Res 2020; 22:e18058. [PMID: 32716302 PMCID: PMC7418009 DOI: 10.2196/18058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 12/30/2022] Open
Abstract
Background Health care delivery for cerebrovascular diseases is a complex process, which may be improved using telestroke networks. Objective The purpose of this work was to establish and implement a protocol for the management of patients with acute stroke symptoms according to the available treatment alternatives at the initial point of care and the transfer possibilities. Methods The review board of our institutions approved this work. The protocol was based on the latest guidelines of the American Heart Association and American Stroke Association. Stroke care requires human and technological resources, which may differ according to the patient’s point of entry into the health care system. Three health care settings were identified to define the appropriate protocols: primary health care setting, intermediate health care setting, and advanced health care setting. Results A user-friendly web-based telestroke solution was developed. The predictors, scales, and scores implemented in this system allowed the assessment of the vascular insult severity and neurological status of the patient. The total number of possible pathways implemented was as follows: 10 in the primary health care setting, 39 in the intermediate health care setting, and 1162 in the advanced health care setting. Conclusions The developed comprehensive telestroke platform is the first stage in optimizing health care delivery for patients with stroke symptoms, regardless of the entry point into the emergency network, in both urban and rural regions. This system supports health care personnel by providing adequate inpatient stroke care and facilitating the prompt transfer of patients to a more appropriate health care setting if necessary, especially for patients with acute ischemic stroke within the therapeutic window who are candidates for reperfusion therapies, ultimately contributing to mitigating the mortality and morbidity associated with stroke.
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Affiliation(s)
- Hernán Bayona
- Primary Stroke Center, Neurology Department, University Hospital Fundación Santa Fe de Bogotá, Bogotá DC, Colombia.,College of Medicine, University of Los Andes, Bogotá DC, Colombia
| | - Brenda Ropero
- Department of Diagnostic Imaging, University Hospital Fundación Santa Fe de Bogotá, Bogotá DC, Colombia
| | - Antonio José Salazar
- Electrophysiology and Telemedicine Laboratory, University of Los Andes, Bogotá DC, Colombia
| | - Juan Camilo Pérez
- Electrophysiology and Telemedicine Laboratory, University of Los Andes, Bogotá DC, Colombia
| | - Manuel Felipe Granja
- Department of Diagnostic Imaging, University Hospital Fundación Santa Fe de Bogotá, Bogotá DC, Colombia.,Lyerly Neurosurgery, Baptist Health, Jacksonville, FL, United States
| | - Carlos Fernando Martínez
- Primary Stroke Center, Neurology Department, University Hospital Fundación Santa Fe de Bogotá, Bogotá DC, Colombia
| | - Juan Nicolás Useche
- Department of Diagnostic Imaging, University Hospital Fundación Santa Fe de Bogotá, Bogotá DC, Colombia
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16
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Tariq S, Sah RG, Chan L, Rajashekar D, McTaggart R, Butcher K, Aviv R, Swartz R, Field T, Tarpley J, Shah R, Hill M, Demchuk A, Goyal M, d'Esterre CD, Barber PA. Recanalization following Endovascular treatment and imaging of PErfusion, Regional inFarction and atrophy to Understand Stroke Evolution-NA1 (REPERFUSE-NA1). Int J Stroke 2020; 15:343-349. [PMID: 32116155 DOI: 10.1177/1747493019895666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
RATIONALE Following endovascular treatment, poor clinical outcomes are more frequent if the initial infarct core or volume of irreversible brain damage is large. Clinical outcomes may be improved using neuroprotective agents that reduce stroke volume and improve recovery. AIM The aim of the REPERFUSE NA1 was to replicate the preclinical neuroprotection study that significantly reduced infarct volume in a primate model of ischemia reperfusion. Specifically, REPERFUSE NA1 will determine if administration of the neuroprotectant NA1 prior to endovascular therapy can significantly reduce early (Day 2 subtract Day 1 diffusion-weighted imaging volume) and delayed secondary infarct (90-day whole brain atrophy plus FLAIR volume-Day 1 diffusion-weighted imaging volume) growth, as measured by magnetic resonance imaging. METHODS AND DESIGN REPERFUSE-NA1 is a magnetic resonance imaging observational substudy of ESCAPE-NA1 (ClinicalTrialGov NCT02930018). A total of 150 acute stroke patients will be recruited (including 20% attrition) that have been randomized to either NA1 or placebo in the ESCAPE-NA1 trial. STUDY OUTCOMES Primary-Early infarct growth measured using diffusion-weighted imaging will be at least 30% smaller in patients receiving NA1 compared to placebo. Secondary-Delayed secondary stroke injury at 90 days will be significantly reduced in patients receiving NA1 compared to placebo, as well as delayed secondary growth at 90 days. CONCLUSION REPERFUSE-NA1 will demonstrate the effect of NA1 neuroprotection on reducing the early and delayed stroke injury after reperfusion treatment.
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Affiliation(s)
- Sana Tariq
- Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Canada.,Seaman Family MR Center, Foothills Medical Centre, Calgary, Canada.,Hotchkiss Brain Institute, Foothills Medical Center, Health Research Innovation Center, Calgary, Canada
| | - Rani Gupta Sah
- Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Canada.,Seaman Family MR Center, Foothills Medical Centre, Calgary, Canada.,Hotchkiss Brain Institute, Foothills Medical Center, Health Research Innovation Center, Calgary, Canada
| | - Leona Chan
- Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Canada.,Seaman Family MR Center, Foothills Medical Centre, Calgary, Canada.,Hotchkiss Brain Institute, Foothills Medical Center, Health Research Innovation Center, Calgary, Canada
| | - Deepthi Rajashekar
- Hotchkiss Brain Institute, Foothills Medical Center, Health Research Innovation Center, Calgary, Canada
| | - Ryan McTaggart
- Department of Neurology and Neurosurgery, Rhode Island Medical Imaging, Providence, RI, USA
| | - Kenneth Butcher
- Division of Neurology, University of Alberta, Edmonton, Canada
| | - Richard Aviv
- Department of Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Rick Swartz
- Department of Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Thalia Field
- Department of Neurology, Gordon and Leslie Diamond, Health Care Centre, Vancouver, Canada
| | - Jason Tarpley
- Pacific Neuroscience Institute, Providence Little Company of Mary Medical Center, Torrance, CA, USA
| | | | - Michael Hill
- Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Canada.,Seaman Family MR Center, Foothills Medical Centre, Calgary, Canada.,Hotchkiss Brain Institute, Foothills Medical Center, Health Research Innovation Center, Calgary, Canada
| | - Andrew Demchuk
- Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Canada.,Seaman Family MR Center, Foothills Medical Centre, Calgary, Canada.,Hotchkiss Brain Institute, Foothills Medical Center, Health Research Innovation Center, Calgary, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Canada.,Seaman Family MR Center, Foothills Medical Centre, Calgary, Canada.,Hotchkiss Brain Institute, Foothills Medical Center, Health Research Innovation Center, Calgary, Canada
| | - Christopher D d'Esterre
- Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Canada.,Seaman Family MR Center, Foothills Medical Centre, Calgary, Canada.,Hotchkiss Brain Institute, Foothills Medical Center, Health Research Innovation Center, Calgary, Canada
| | - Philip A Barber
- Department of Clinical Neurosciences, Foothills Medical Centre, Calgary, Canada.,Seaman Family MR Center, Foothills Medical Centre, Calgary, Canada.,Hotchkiss Brain Institute, Foothills Medical Center, Health Research Innovation Center, Calgary, Canada
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17
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Affiliation(s)
- Patrick D Lyden
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
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18
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Chalos V, van der Ende NAM, Lingsma HF, Mulder MJHL, Venema E, Dijkland SA, Berkhemer OA, Yoo AJ, Broderick JP, Palesch YY, Yeatts SD, Roos YBWEM, van Oostenbrugge RJ, van Zwam WH, Majoie CBLM, van der Lugt A, Roozenbeek B, Dippel DWJ. National Institutes of Health Stroke Scale: An Alternative Primary Outcome Measure for Trials of Acute Treatment for Ischemic Stroke. Stroke 2019; 51:282-290. [PMID: 31795895 PMCID: PMC6924951 DOI: 10.1161/strokeaha.119.026791] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Supplemental Digital Content is available in the text. The modified Rankin Scale (mRS) at 3 months is the most commonly used primary outcome measure in stroke treatment trials, but it lacks specificity and requires long-term follow-up interviews, which consume time and resources. An alternative may be the National Institutes of Health Stroke Scale (NIHSS), early after stroke. Our aim was to evaluate whether the NIHSS assessed within 1 week after treatment could serve as a primary outcome measure for trials of acute treatment for ischemic stroke.
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Affiliation(s)
- Vicky Chalos
- From the Departments of Neurology (V.C., N.A.M.v.d.E., M.J.H.L.M., E.V., O.A.B., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Public Health (V.C., H.F.L., E.V., S.A.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Radiology and Nuclear Medicine (V.C., N.A.M.v.d.E., O.A.B., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nadinda A M van der Ende
- From the Departments of Neurology (V.C., N.A.M.v.d.E., M.J.H.L.M., E.V., O.A.B., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Radiology and Nuclear Medicine (V.C., N.A.M.v.d.E., O.A.B., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Public Health (V.C., H.F.L., E.V., S.A.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maxim J H L Mulder
- From the Departments of Neurology (V.C., N.A.M.v.d.E., M.J.H.L.M., E.V., O.A.B., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Esmee Venema
- From the Departments of Neurology (V.C., N.A.M.v.d.E., M.J.H.L.M., E.V., O.A.B., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Public Health (V.C., H.F.L., E.V., S.A.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Simone A Dijkland
- Public Health (V.C., H.F.L., E.V., S.A.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Olvert A Berkhemer
- From the Departments of Neurology (V.C., N.A.M.v.d.E., M.J.H.L.M., E.V., O.A.B., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Radiology and Nuclear Medicine (V.C., N.A.M.v.d.E., O.A.B., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Departments of Radiology and Nuclear Medicine (O.A.B., C.B.L.M.M.), Amsterdam UMC, Location AMC, University of Amsterdam, the Netherlands.,Radiology (O.A.B., W.H.v.Z.), Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands
| | - Albert J Yoo
- Department of Interventional Neuroradiology, Texas Stroke Institute, Dallas-Fort Worth (A.J.Y.)
| | - Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, OH (J.P.B.)
| | - Yuko Y Palesch
- Department of Public Health Sciences, Medical University of South Carolina, Charleston (Y.Y.P., S.D.Y.)
| | - Sharon D Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston (Y.Y.P., S.D.Y.)
| | - Yvo B W E M Roos
- Neurology (Y.B.W.E.M.R.), Amsterdam UMC, Location AMC, University of Amsterdam, the Netherlands
| | - Robert J van Oostenbrugge
- Departments of Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands
| | - Wim H van Zwam
- Radiology (O.A.B., W.H.v.Z.), Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands
| | - Charles B L M Majoie
- Departments of Radiology and Nuclear Medicine (O.A.B., C.B.L.M.M.), Amsterdam UMC, Location AMC, University of Amsterdam, the Netherlands
| | - Aad van der Lugt
- Radiology and Nuclear Medicine (V.C., N.A.M.v.d.E., O.A.B., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- From the Departments of Neurology (V.C., N.A.M.v.d.E., M.J.H.L.M., E.V., O.A.B., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Radiology and Nuclear Medicine (V.C., N.A.M.v.d.E., O.A.B., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- From the Departments of Neurology (V.C., N.A.M.v.d.E., M.J.H.L.M., E.V., O.A.B., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Qualitative Posttreatment Diffusion-Weighted Imaging as a Predictor of 90-day Outcome in Stroke Intervention. Can J Neurol Sci 2019; 47:160-166. [PMID: 31779719 DOI: 10.1017/cjn.2019.330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE The aim was to assess the ability of post-treatment diffusion-weighted imaging (DWI) to predict 90-day functional outcome in patients with endovascular therapy (EVT) for large vessel occlusion in acute ischemic stroke (AIS). METHODS We examined a retrospective cohort from March 2016 to January 2018, of consecutive patients with AIS who received EVT. Planimetric DWI was obtained and infarct volume calculated. Four blinded readers were asked to predict modified Rankin Score (mRS) at 90 days post-thrombectomy. RESULTS Fifty-one patients received endovascular treatment (mean age 65.1 years, median National Institutes of Health Stroke Scale (NIHSS) 18). Mean infarct volume was 43.7 mL. The baseline NIHSS, 24-hour NIHSS, and the DWI volume were lower for the mRS 0-2 group. Also, the thrombolysis in cerebral infarction (TICI) 2b/3 rate was higher in the mRS 0-2 group. No differences were found in terms of the occlusion level, reperfusion technique, or recombinant tissue plasminogen activator use. There was a significant association noted between average infarct volume and mRS at 90 days. On multivariable analysis, higher infarct volume was significantly associated with 90-day mRS 3-5 when adjusted to TICI scores and occlusion location (OR 1.01; CI 95% 1.001-1.03; p = 0.008). Area under curve analysis showed poor performance of DWI volume reader ability to qualitatively predict 90-day mRS. CONCLUSION The subjective impression of DWI as a predictor of clinical outcome is poorly correlated when controlling for premorbid status and other confounders. Qualitative DWI by experienced readers both overestimated the severity of stroke for patients who achieved good recovery and underestimated the mRS for poor outcome patients. Infarct core quantitation was reliable.
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Kim JS, Lee KB, Park JH, Sung SM, Oh K, Kim EG, Chang DI, Hwang YH, Lee EJ, Kim WK, Ju C, Kim BS, Ryu JM. Safety and Efficacy of Otaplimastat in Patients with Acute Ischemic Stroke Requiring tPA (SAFE-TPA): A Multicenter, Randomized, Double-Blind, Placebo-Controlled Phase 2 Study. Ann Neurol 2019; 87:233-245. [PMID: 31721277 PMCID: PMC7003891 DOI: 10.1002/ana.25644] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 10/22/2019] [Accepted: 11/10/2019] [Indexed: 12/30/2022]
Abstract
Objective Otaplimastat is a neuroprotectant that inhibits matrix metalloprotease pathway, and reduces edema and intracerebral hemorrhage induced by recombinant tissue plasminogen activator (rtPA) in animal stroke models. We aimed to assess the safety and efficacy of otaplimastat in patients receiving rtPA. Methods This was a phase 2, 2‐part, multicenter trial in stroke patients (19–80 years old) receiving rtPA. Intravenous otaplimastat was administered <30 minutes after rtPA. Stage 1 was a single‐arm, open‐label safety study in 11 patients. Otaplimastat 80 mg was administered twice daily for 3 days. Stage 2 was a randomized, double‐blind, placebo‐controlled study involving 69 patients, assigned (1:1:1) to otaplimastat 40 mg, otaplimastat 80 mg, or a placebo. The primary endpoint was the occurrence of parenchymal hematoma (PH) on day 1. Secondary endpoints included serious adverse events (SAEs), mortality, and modified Rankin scale (mRS) distribution at 90 days (http://clinicaltrials.gov identifier: NCT02787278). Results No safety issues were encountered in stage 1. The incidence of PH during stage 2 was comparable: 0 of 22 with the placebo, 0 of 22 with otaplimastat 40 mg, and 1 of 21 with the 80 mg dose. No differences in SAEs (13%, 17%, 14%) or death (8.3%, 4.2%, 4.8%) were observed among the 3 groups. Three adverse events (chills, muscle rigidity, hepatotoxicity) were judged to be related to otaplimastat. Interpretation Intravenous otaplimastat adjunctive therapy in patients receiving rtPA is feasible and generally safe. The functional efficacy of otaplimastat needs to be investigated with further large trials. ANN NEUROL 2020;87:233–245
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Affiliation(s)
- Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University School of Medicine, Seoul
| | - Jong-Ho Park
- Department of Neurology, Myongji Hospital, Hanyang University College of Medicine, Goyang
| | - Sang Min Sung
- Department of Neurology, Pusan National University Hospital, Busan
| | - Kyungmi Oh
- Department of Neurology, Korea University Guro Hospital, Seoul
| | - Eung-Gyu Kim
- Department of Neurology, Inje University Busan Paik Hospital, Busan
| | - Dae-Il Chang
- Department of Neurology, Kyung Hee University Hospital, Seoul
| | - Yang Ha Hwang
- Department of Neurology, Kyungpook National University School of Medicine and Hospital, Daegu
| | - Eun-Jae Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul
| | - Won-Ki Kim
- Department of Neuroscience, Korea University College of Medicine, Seoul
| | - Chung Ju
- Research Headquarters, Shin Poong Pharmaceutical, Ansan, Korea
| | - Byung Su Kim
- Research Headquarters, Shin Poong Pharmaceutical, Ansan, Korea
| | - Jei-Man Ryu
- Research Headquarters, Shin Poong Pharmaceutical, Ansan, Korea
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Silva AL, Pessoa AS, Nogueira R, Araújo JM, Alves JN, Pinho J, Ferreira C. Prognostic information of gaze deviation in acute ischemic stroke patients. Neurol Sci 2019; 41:435-440. [PMID: 31713194 DOI: 10.1007/s10072-019-04140-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/03/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Gaze deviation (GD) in acute ischemic stroke patients has been suggested to be associated with poor outcome and with the presence of large vessel occlusion. Our aim was to study the prognostic significance of GD in ischemic stroke patients submitted to acute revascularization treatments. METHODS Retrospective single-center study of consecutive anterior circulation ischemic stroke patients submitted to thrombolysis and/or endovascular revascularization between 2007 and 2017. The groups of patients with and without GD were compared concerning baseline clinical and imagiological variables, functional outcome at 3 months, and survival at 1 year. RESULTS Among a study population of 711 patients, 332 (46.7%) presented GD. Patients with GD were more frequently of female sex (p = 0.048), had higher baseline NIHSS scores (p < 0.001), had lower ASPECTS on baseline CT (p < 0.001), more frequently had ischemia of the right hemisphere (p < 0.001), presented higher NIHSS 24 hours after treatment (p < 0.001), and more frequently presented cardioembolic stroke (p = 0.003). In the unadjusted analyses, GD was associated with decreased 3-month functional independence and increased 1-month and 1 year mortality (p < 0.001). After adjustment for variables of interest, namely, for NIHSS 24 hours after treatment, GD was no longer associated with functional outcome or survival. CONCLUSIONS GD in patients with acute ischemic stroke is associated with increased clinical and imagiological severity at baseline. However, in patients submitted to acute revascularization treatments, this does not appear to be independent predictor of functional outcome or survival.
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Affiliation(s)
- Ana Lima Silva
- Internal Medicine Department, Centro Hospitalar Médio Ave., Rua Cupertino de Miranda, 4761-917, V. N. de Famalicão, Portugal
| | - Ana Sofia Pessoa
- Internal Medicine Department, Centro Hospitalar Médio Ave., Rua Cupertino de Miranda, 4761-917, V. N. de Famalicão, Portugal
| | - Renato Nogueira
- Internal Medicine Department, Centro Hospitalar Médio Ave., Rua Cupertino de Miranda, 4761-917, V. N. de Famalicão, Portugal
| | - José Manuel Araújo
- Neurology Department, Hospital de Braga, Sete Fontes, São Victor, 4715-243, Braga, Portugal
| | - José Nuno Alves
- Neurology Department, Hospital de Braga, Sete Fontes, São Victor, 4715-243, Braga, Portugal
| | - João Pinho
- Department of Neurology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Carla Ferreira
- Neurology Department, Hospital de Braga, Sete Fontes, São Victor, 4715-243, Braga, Portugal
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22
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Puig J, Blasco G, Alberich-Bayarri A, Schlaug G, Deco G, Biarnes C, Navas-Martí M, Rivero M, Gich J, Figueras J, Torres C, Daunis-I-Estadella P, Oramas-Requejo CL, Serena J, Stinear CM, Kuceyeski A, Soriano-Mas C, Thomalla G, Essig M, Figley CR, Menon B, Demchuk A, Nael K, Wintermark M, Liebeskind DS, Pedraza S. Resting-State Functional Connectivity Magnetic Resonance Imaging and Outcome After Acute Stroke. Stroke 2019; 49:2353-2360. [PMID: 30355087 DOI: 10.1161/strokeaha.118.021319] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Physiological effects of stroke are best assessed over entire brain networks rather than just focally at the site of structural damage. Resting-state functional magnetic resonance imaging can map functional-anatomic networks by analyzing spontaneously correlated low-frequency activity fluctuations across the brain, but its potential usefulness in predicting functional outcome after acute stroke remains unknown. We assessed the ability of resting-state functional magnetic resonance imaging to predict functional outcome after acute stroke. Methods- We scanned 37 consecutive reperfused stroke patients (age, 69±14 years; 14 females; 3-day National Institutes of Health Stroke Scale score, 6±5) on day 3 after symptom onset. After imaging preprocessing, we used a whole-brain mask to calculate the correlation coefficient matrices for every paired region using the Harvard-Oxford probabilistic atlas. To evaluate functional outcome, we applied the modified Rankin Scale at 90 days. We used region of interest analyses to explore the functional connectivity between regions and graph-computation analysis to detect differences in functional connectivity between patients with good functional outcome (modified Rankin Scale score ≤2) and those with poor outcome (modified Rankin Scale score >2). Results- Patients with good outcome had greater functional connectivity than patients with poor outcome. Although 3-day National Institutes of Health Stroke Scale score was the most accurate independent predictor of 90-day modified Rankin Scale (84.2%), adding functional connectivity increased accuracy to 94.7%. Preserved bilateral interhemispheric connectivity between the anterior inferior temporal gyrus and superior frontal gyrus and decreased connectivity between the caudate and anterior inferior temporal gyrus in the left hemisphere had the greatest impact in favoring good prognosis. Conclusions- These data suggest that information about functional connectivity from resting-state functional magnetic resonance imaging may help predict 90-day stroke outcome.
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Affiliation(s)
- Josep Puig
- From the Imaging Research Unit, Department of Radiology (Girona Biomedical Research Institute) Girona Biomedical Research Institute, Diagnostic Imaging Institute (IDI) (J.P., G.B., C.B., M.N.-M., C.L.O.-R., S.P.), Dr Josep Trueta University Hospital, Girona, Spain
| | - Gerard Blasco
- From the Imaging Research Unit, Department of Radiology (Girona Biomedical Research Institute) Girona Biomedical Research Institute, Diagnostic Imaging Institute (IDI) (J.P., G.B., C.B., M.N.-M., C.L.O.-R., S.P.), Dr Josep Trueta University Hospital, Girona, Spain
| | - Angel Alberich-Bayarri
- Quantitative Imaging Biomarkers In Medicine, La Fe Health Research Institute, La Fe Polytechnics and University Hospital, Valencia, Spain (A.A.-B.)
| | - Gottfried Schlaug
- Neuroimaging and Stroke Recovery Laboratory, Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (G.S.)
| | - Gustavo Deco
- Center for Brain and Cognition, Universitat Pompeu Fabra, Barcelona, Spain (G.D.).,ICREA Institut Catalan de Recerca i Estudis Avançats, Barcelona, Spain (G.D.)
| | - Carles Biarnes
- From the Imaging Research Unit, Department of Radiology (Girona Biomedical Research Institute) Girona Biomedical Research Institute, Diagnostic Imaging Institute (IDI) (J.P., G.B., C.B., M.N.-M., C.L.O.-R., S.P.), Dr Josep Trueta University Hospital, Girona, Spain
| | - Marian Navas-Martí
- From the Imaging Research Unit, Department of Radiology (Girona Biomedical Research Institute) Girona Biomedical Research Institute, Diagnostic Imaging Institute (IDI) (J.P., G.B., C.B., M.N.-M., C.L.O.-R., S.P.), Dr Josep Trueta University Hospital, Girona, Spain
| | - Mireia Rivero
- Department of Neurology, Girona Biomedical Research Institute (M.R., J.G., J.S.), Dr Josep Trueta University Hospital, Girona, Spain
| | - Jordi Gich
- Department of Neurology, Girona Biomedical Research Institute (M.R., J.G., J.S.), Dr Josep Trueta University Hospital, Girona, Spain
| | - Jaume Figueras
- Department of Rehabilitation (J.F., C.T.), Dr Josep Trueta University Hospital, Girona, Spain
| | - Cristina Torres
- Department of Rehabilitation (J.F., C.T.), Dr Josep Trueta University Hospital, Girona, Spain
| | - Pepus Daunis-I-Estadella
- Department of Computer Science, Applied Mathematics, and Statistics, University of Girona, Spain (P.D.-i.-E.)
| | - Celia L Oramas-Requejo
- From the Imaging Research Unit, Department of Radiology (Girona Biomedical Research Institute) Girona Biomedical Research Institute, Diagnostic Imaging Institute (IDI) (J.P., G.B., C.B., M.N.-M., C.L.O.-R., S.P.), Dr Josep Trueta University Hospital, Girona, Spain
| | - Joaquín Serena
- Department of Neurology, Girona Biomedical Research Institute (M.R., J.G., J.S.), Dr Josep Trueta University Hospital, Girona, Spain
| | - Cathy M Stinear
- Department of Medicine, Centre for Brain Research, University of Auckland, New Zealand (C.M.S.)
| | - Amy Kuceyeski
- Department of Radiology, Weill Cornell Medical College, NY (A.K.)
| | - Carles Soriano-Mas
- Department of Psychiatry, Bellvitge University Hospital-Instituto de Investigación Biomédica de Bellvitge, Hospitalet del Llobregat, Barcelona, Spain (C.S.-M.).,Centro de Investigación en Salud Mental, Barcelona, Spain (C.S.-M.).,Department of Psychobiology and Methodology in Health Sciences, Universitat Autonoma de Barcelona, Spain (C.S.-M.)
| | - Götz Thomalla
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany (G.T.)
| | - Marco Essig
- Department of Radiology, University of Manitoba, Winnipeg, Canada (M.E., C.R.F.)
| | - Chase R Figley
- Department of Radiology, University of Manitoba, Winnipeg, Canada (M.E., C.R.F.)
| | - Bijoy Menon
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (B.M., A.D.)
| | - Andrew Demchuk
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (B.M., A.D.)
| | - Kambiz Nael
- Department of Radiology, Icahn School of Medicine at Mount Sinai, NY (K.N.)
| | - Max Wintermark
- Neuroradiology Division, Department of Radiology, Stanford University, Palo Alto, CA (M.W.)
| | - David S Liebeskind
- Neurovascular Imaging Research Core and University of California Los Angeles Stroke Center, Los Angeles, CA (D.S.L.)
| | - Salvador Pedraza
- From the Imaging Research Unit, Department of Radiology (Girona Biomedical Research Institute) Girona Biomedical Research Institute, Diagnostic Imaging Institute (IDI) (J.P., G.B., C.B., M.N.-M., C.L.O.-R., S.P.), Dr Josep Trueta University Hospital, Girona, Spain
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Cheng KH, Lin JR, Anderson CS, Lai WT, Lee TH. Lipid Paradox in Statin-Naïve Acute Ischemic Stroke But Not Hemorrhagic Stroke. Front Neurol 2018; 9:541. [PMID: 30210423 PMCID: PMC6124481 DOI: 10.3389/fneur.2018.00541] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 06/18/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Low lipid level is associated with better cardiovascular outcome. However, lipid paradox indicating low lipid level having worse outcomes could be seen under acute injury in some diseases. The present study was designed to clarify the prognostic significance of acute-phase lipid levels within 1 day after admission for stroke on mortality in first-ever statin-naïve acute ischemic stroke (IS) and hemorrhagic stroke (HS). Methods: This observational study was conducted using the data collected from Stroke Registry In Chang-Gung Healthcare System (SRICHS) between 2009 and 2012. Patients with recurrent stroke, onset of symptoms >1 day, and history of the use of lipid-lowering agents prior to index stroke were excluded. Stroke was classified into IS and hypertension-related HS. The primary outcomes were 30-day and 1-year mortality identified by linkage to national death registry for date and cause of death. Receiver operating characteristic (ROC) curve analysis and multivariate Cox proportional hazard models were used to examine the association of lipid profiles on admission with mortality. Results: Among the 18,268 admitted stroke patients, 3,746 IS and 465 HS patients were eligible for analysis. In IS, total cholesterol (TC) <163.5 mg/dL, triglyceride (TG) <94.5 mg/dL, low-density lipoprotein (LDL) <100 mg/dL, non-high-density lipoprotein cholesterol (non-HDL-C) <130.5 mg/dL, and TC/HDL ratio <4.06 had significantly higher risk for 30-day/1-year mortality with hazard ratio (HR) of 2.05/1.37, 1.65/1.31, 1.68/1.38, 1.80/1.41, and 1.58/1.38, respectively, compared with high TC, TG, LDL, non-HDL-C, and TC/HDL ratio (p < 0.01 in all cases). In HS, lipid profiles were not associated with mortality, except HDL for 30-day mortality (p = 0.025) and high uric acid (UA) concentrations for 30-day and 1-year mortality (p = 0.002 and 0.012, respectively). High fasting glucose and high National Institute of Health Stroke Scale (NIHSS) score at admission were associated with higher 30-day and 1-year mortality in both IS and HS and low blood pressure only in IS (p < 0.05). Synergic effects on mortality were found when low lipids were incorporated with high fasting glucose, low blood pressure, and high NIHSS score in IS (p < 0.05). Conclusions: Lipid paradox showing low acute-phase lipid levels with high mortality could be seen in statin-naïve acute IS but not in HS. The mortality in IS was increased when low lipids were incorporated with high fasting glucose, low blood pressure, and high NIHSS score.
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Affiliation(s)
- Kai-Hung Cheng
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jr-Rung Lin
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Craig S Anderson
- Neurological and Mental Health Division, The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Wen-Ter Lai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Validation of Serial Alberta Stroke Program Early CT Score as an Outcome Predictor in Thrombolyzed Stroke Patients. J Stroke Cerebrovasc Dis 2017; 26:2264-2271. [PMID: 28601259 DOI: 10.1016/j.jstrokecerebrovasdis.2017.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 05/04/2017] [Accepted: 05/07/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The Alberta Stroke Program Early CT Score (ASPECTS) on baseline imaging is an established predictor of functional outcome in anterior circulation acute ischemic stroke (AIS). We studied ASPECTS before intravenous thrombolysis (IVT) and at 24 hours to assess its prognostic value. METHODS Data for consecutive anterior circulation AIS patients treated with IVT from 2006 to 2013 were extracted from a prospectively managed registry at our tertiary center. Pre-thrombolysis and 24-hour ASPECTS were evaluated by 2 independent neuroradiologists. Outcome measures included symptomatic intracranial hemorrhage (SICH), modified Rankin Scale (mRS) at 90 days, and mortality. Unfavorable functional outcome was defined by mRS >1. Dramatic ASPECTS progression (DAP) was defined as deterioration in ASPECTS by 6 points or more. RESULTS Of 554 AIS patients thrombolyzed during the study period, 400 suffered from anterior circulation infarction. The median age was 65 years (interquartile range (IQR): 59-70) and the median National Institutes of Health Stroke Scale score was 18 points (IQR: 12-22). Compared with the pre-IVT ASPECTS (area under the curve [AUC] = .64, 95% confidence interval [CI]: .54-.65, P = .001), ASPECTS on the 24-hour CT scan (AUC = .78, 95% CI: .73-.82, P < .001), and change in ASPECTS (AUC = .69, 95% CI: .64-.74, P < .001) were better predictors of unfavorable functional outcome at 3 months. DAP, noted in 34 (14.4%) patients with good baseline ASPECTS (8-10 points), was significantly associated with unfavorable functional outcome (odds ratio [OR]: 9.91, 95% CI: 3.37-29.19, P ≤ .001), mortality (OR: 21.99, 95% CI: 7.98-60.58, P < .001), and SICH (OR: 8.57, 95% CI: 2.87-25.59, P < .001). CONCLUSION Compared with the pre-thrombolysis score, ASPECTS measured at 24 hours as well as serial change in ASPECTS is a better predictor of 3-month functional outcome.
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Hussein HM, Niemann N, Parker ED, Qureshi AI. Searching for the Smoker’s Paradox in Acute Stroke Patients Treated With Intravenous Thrombolysis. Nicotine Tob Res 2017; 19:871-876. [DOI: 10.1093/ntr/ntx020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 01/18/2017] [Indexed: 11/14/2022]
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Lyden P, Hemmen T, Grotta J, Rapp K, Ernstrom K, Rzesiewicz T, Parker S, Concha M, Hussain S, Agarwal S, Meyer B, Jurf J, Altafullah I, Raman R. Results of the ICTuS 2 Trial (Intravascular Cooling in the Treatment of Stroke 2). Stroke 2016; 47:2888-2895. [PMID: 27834742 DOI: 10.1161/strokeaha.116.014200] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 09/13/2016] [Accepted: 10/05/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE Therapeutic hypothermia is a potent neuroprotectant approved for cerebral protection after neonatal hypoxia-ischemia and cardiac arrest. Therapeutic hypothermia for acute ischemic stroke is safe and feasible in pilot trials. We designed a study protocol to provide safer, faster therapeutic hypothermia in stroke patients. METHODS Safety procedures and 4°C saline infusions for faster cooling were added to the ICTuS trial (Intravascular Cooling in the Treatment of Stroke) protocol. A femoral venous intravascular cooling catheter after intravenous recombinant tissue-type plasminogen activator in eligible patients provided 24 hours cooling followed by a 12-hour rewarm. Serial safety assessments and imaging were performed. The primary end point was 3-month modified Rankin score 0,1. RESULTS Of the intended 1600 subjects, 120 were enrolled before the study was stopped. Randomly, 63 were to receive hypothermia plus antishivering treatment and 57 normothermia. Compared with previous studies, cooling rates were improved with a cold saline bolus, without fluid overload. The intention-to-treat primary outcome of 90-day modified Rankin Score 0,1 occurred in 33% hypothermia and 38% normothermia subjects, odds ratio (95% confidence interval) of 0.81 (0.36-1.85). Serious adverse events occurred equally. Mortality was 15.9% hypothermia and 8.8% normothermia subjects, odds ratio (95% confidence interval) of 1.95 (0.56-7.79). Pneumonia occurred in 19% hypothermia versus 10.5% in normothermia subjects, odds ratio (95% confidence interval) of 1.99 (0.63-6.98). CONCLUSIONS Intravascular therapeutic hypothermia was confirmed to be safe and feasible in recombinant tissue-type plasminogen activator-treated acute ischemic stroke patients. Protocol changes designed to reduce pneumonia risk appeared to fail, although the sample is small. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01123161.
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Affiliation(s)
- Patrick Lyden
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.).
| | - Thomas Hemmen
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - James Grotta
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Karen Rapp
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Karin Ernstrom
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Teresa Rzesiewicz
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Stephanie Parker
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Mauricio Concha
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Syed Hussain
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Sachin Agarwal
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Brett Meyer
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Julie Jurf
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Irfan Altafullah
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Rema Raman
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
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The Combination of Clinical Features, Transcranial Doppler, and Alberta Stroke Program Early Computed Tomography Score (Computed Tomography Angiography) in Predicting Outcome in Intravenous Recombinant Tissue Plasminogen Activator-Treated Patients. J Stroke Cerebrovasc Dis 2016; 25:2019-23. [PMID: 27241578 DOI: 10.1016/j.jstrokecerebrovasdis.2015.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/09/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Little data exist on using combined baseline clinical neuroimaging and transcranial Doppler (TCD) information in predicting clinical outcome in stroke patients treated with intravenous (IV) thrombolysis. METHODS Stroke patients received IV recombinant tissue plasminogen activator (rt-PA) and had diagnostic TCD within 3 hours of symptom onset. The TCD result was interpreted using the thrombolysis in brain ischemia (TIBI) flow grading system. Following multiple regression analysis, a grading system was created with 1 point for each of the following: National Institutes of Health Stroke Scale (NIHSS) score of 16 or higher, TIBI score of 1 or lower, and Alberta Stroke Program Early CT Score (ASPECTS) of 6 or lower. The patients' scores were compared to modified Rankin Scale (mRS) scores at 90 days. RESULTS A total of 349 patients were included. In unvaried analysis, age of 80 years or older (P = .002), an ASPECTS of 6 or lower (P < .001), an NIHSS score of 16 or higher (P < .001), a TIBI score of 1 or lower (P < .001), and a glucose level ≥ 200 mg/dl (P = .04) were associated with poor outcome (mRS score > 2). In the multiple regression analysis, age of 80 years or older, an ASPECTS of 6 or lower, an NIHSS score of 16 or higher, and hyperglycemia were predictors of poor outcome (P < .05). Based on our scoring system, the patients' odds ratios for poor outcome were 7 (95% confidence interval [CI]: 2-23, P = .003), 8 (95% CI: 3-25, P < .001), and 24 (95% CI: 4-151, P = .001) for scores of 1, 2, and 3, respectively, after adjustment for common stroke risk factors. The mean time to recanalization increased as the score increased (score of 0: 160 ± 45 minutes versus score of 3: 186 ± 38 (P = .70). CONCLUSION A multimodal grading system is useful in predicting outcome in patients treated with IV rt-PA. Those withhigher scores might be candidates for interventional therapy.
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Shams T, Zaidat O, Yavagal D, Xavier A, Jovin T, Janardhan V. Society of Vascular and Interventional Neurology (SVIN) Stroke Interventional Laboratory Consensus (SILC) Criteria: A 7M Management Approach to Developing a Stroke Interventional Laboratory in the Era of Stroke Thrombectomy for Large Vessel Occlusions. INTERVENTIONAL NEUROLOGY 2016; 5:1-28. [PMID: 27610118 PMCID: PMC4934489 DOI: 10.1159/000443617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Brain attack care is rapidly evolving with cutting-edge stroke interventions similar to the growth of heart attack care with cardiac interventions in the last two decades. As the field of stroke intervention is growing exponentially globally, there is clearly an unmet need to standardize stroke interventional laboratories for safe, effective, and timely stroke care. Towards this goal, the Society of Vascular and Interventional Neurology (SVIN) Writing Committee has developed the Stroke Interventional Laboratory Consensus (SILC) criteria using a 7M management approach for the development and standardization of each stroke interventional laboratory within stroke centers. The SILC criteria include: (1) manpower: personnel including roles of medical and administrative directors, attending physicians, fellows, physician extenders, and all the key stakeholders in the stroke chain of survival; (2) machines: resources needed in terms of physical facilities, and angiography equipment; (3) materials: medical device inventory, medications, and angiography supplies; (4) methods: standardized protocols for stroke workflow optimization; (5) metrics (volume): existing credentialing criteria for facilities and stroke interventionalists; (6) metrics (quality): benchmarks for quality assurance; (7) metrics (safety): radiation and procedural safety practices.
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Affiliation(s)
- Tanzila Shams
- Texas Stroke Institute, HCA North Texas Division, Dallas-Fort Worth, Tex., USA
| | - Osama Zaidat
- Mercy Neuroscience and Stroke Center, Toledo, Ohio, USA
| | - Dileep Yavagal
- Jackson Memorial Hospital, University of Miami Health System, Miami, Fla., USA
| | - Andrew Xavier
- Detroit Medical Center, Wayne State University, Detroit, Mich., USA
| | - Tudor Jovin
- UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburg, Pa., USA
| | - Vallabh Janardhan
- Texas Stroke Institute, HCA North Texas Division, Dallas-Fort Worth, Tex., USA
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Rangaraju S, Frankel M, Jovin TG. Prognostic Value of the 24-Hour Neurological Examination in Anterior Circulation Ischemic Stroke: A post hoc Analysis of Two Randomized Controlled Stroke Trials. INTERVENTIONAL NEUROLOGY 2016; 4:120-9. [PMID: 27051408 DOI: 10.1159/000443801] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Early prognostication of long-term outcomes following ischemic stroke can facilitate medical decision-making. We hypothesized that the 24-hour National Institute of Health Stroke Scale (NIHSS) predicts 3-month clinical outcomes in anterior circulation stroke. METHODS Secondary analyses of the Interventional Management of Stroke 3 (IMS3) and intravenous tissue plasminogen activator (IV tPA) for acute ischemic stroke [National Institute of Neurological Diseases and Stroke (NINDS) IV tPA] trials were performed. In participants with documented 24-hour NIHSS and 3-month Modified Rankin Scale (mRS), the predictive power of the 24-hour NIHSS and 24-hour NIHSS improvement for 3-month outcomes [mRS 0-2 and Barthel Index (BI) ≥95] was assessed. Percentages of good outcome (mRS 0-2 or BI ≥95) at 3, 6, and 12 months and mean quality of life (EQ5D™) index at 3 months across 24-hour NIHSS quartiles were compared. RESULTS The majority of the study participants were included (IMS3 n = 587/656, NINDS IV tPA n = 619/624). The 24-hour NIHSS was correlated with 3-month mRS (R = 0.73) with excellent predictive power for mRS 0-2 [area under the curve (AUC) = 0.91] and BI ≥95 (AUC = 0.9) in both cohorts. A model with the 24-hour NIHSS alone correctly classified 82-84% of patients in both cohorts. The percentages of good outcomes at 3-12 months across 24-hour NIHSS quartiles were similar in both cohorts. mRS 0-2 was achieved by 75.6-77.7% of patients with 24-hour NIHSS ≤11 but by only 1.4-3.6% with 24-hour NIHSS ≥20. The EQ5D index at 3 months varied among NIHSS 0-4 (mean 0.86 ± 0.16), 5-11 (0.77 ± 0.18), and 12-19 (0.59 ± 0.26) quartiles. CONCLUSIONS The 24-hour NIHSS strongly predicts long-term stroke outcomes and is associated with quality of life. Its easy availability, reliability, and validity support its use as an early prognostic marker and surrogate of clinical outcome in ischemic stroke.
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Affiliation(s)
| | | | - Tudor G Jovin
- University of Pittsburgh Medical Center, Pittsburgh, Pa., USA
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Intravenous Thrombolysis. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00051-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
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Park JH, Ovbiagele B. Relationship of functional disability after a recent stroke with recurrent stroke risk. Eur J Neurol 2015; 23:361-7. [PMID: 26493027 DOI: 10.1111/ene.12837] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 08/04/2015] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE Post-stroke disability status is primarily focused on recovery prognostication but the influence of post-stroke disability on future vascular risk is unknown. The relationship between functional disability after an index stroke and risk of recurrent vascular events was examined. METHODS A cohort analysis of 3680 recent non-cardioembolic, non-to-moderate disabled [modified Rankin Scale (mRS) ≤3] stroke patients aged ≥35 years and followed for 2 years was reviewed. The mRS measured at a median of 35 days after the index stroke was analyzed as a dichotomous variable (mRS 3 vs. ≤2) and in a stepwise manner. Independent associations of post-stroke disability by mRS score with ischaemic stroke (primary outcome), stroke/coronary heart disease/vascular death as major vascular events (secondary outcome) and all-cause death (tertiary outcome) were analyzed. RESULTS Amongst study participants, 435 (11.8%) had an mRS of 3. Compared with mRS ≤2 as no/slight disability, mRS 3 as moderate disability was associated with a higher risk of stroke (adjusted hazard ratio 1.45, 95% confidence interval 1.06-1.99). Compared with mRS 0, there was a progressively higher independent risk for each of the study outcomes: stroke, mRS 1 (1.42, 0.97-2.08), mRS 2 (1.46, 0.97-2.20), mRS 3 (1.89, 1.20-2.97); major vascular events, mRS 1 (1.31, 1.01-1.70), mRS 2 (1.31, 0.99-1.74), mRS 3 (1.46, 1.06-2.01); and all-cause death, mRS 1 (1.75, 1.03-2.98), mRS 2 (2.49, 1.44-4.31), mRS 3 (2.72, 1.43-5.19). CONCLUSION Compared with no/slight disability, moderate disability after a recent stroke is linked to a higher risk of recurrent stroke.
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Affiliation(s)
- J-H Park
- Department of Neurology, Seonam University Myongji Hospital, Goyang, South Korea.,Department of Neurosciences, Medical University of South Carolina, Charleston, SC, USA
| | - B Ovbiagele
- Department of Neurosciences, Medical University of South Carolina, Charleston, SC, USA
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United States trends in thrombolysis for older adults with acute ischemic stroke. Clin Neurol Neurosurg 2015; 139:16-23. [PMID: 26363362 DOI: 10.1016/j.clineuro.2015.08.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/05/2015] [Accepted: 08/25/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Thrombolysis for ischemic stroke has been increasing in the United States. We sought to investigate recent trends in thrombolysis use in older adults. METHODS A retrospective, observational analysis of hospitalization data from the Nationwide Inpatient Sample (NIS) in 2005-2010 was performed. Older adults (≥65 years) admitted with a primary diagnosis of acute ischemic stroke were included. Trends in the population-based rates of thrombolysis and outcomes from the NIS were evaluated using the Cochran-Armitage test. RESULTS Thrombolysis in older adult stroke patients increased from 1.7% to 5.4% (2005-2010; trend P<0.001). Large increases were observed among urban patients, urban hospitals, and high volume facilities. Individuals ≥85 years were less likely to receive thrombolysis than younger ages throughout the study period, although there was an increase from an odds ratio of 0.50 (95% CI: 0.44-0.57) to 0.75 (95% CI: 0.69-0.81) from 2005-2006 to 2009-2010 when compared to 65-74 year olds. For those receiving thrombolysis, no change was observed in intracerebral hemorrhage over time. In-hospital mortality rates did not change significantly over the study period for age subgroups and length of stay declined from 2005 to 2010 for the thrombolysis group (7.6 vs 7.0 days; trend P<0.001). CONCLUSIONS Rates of thrombolysis in older adults progressively increased, especially in the oldest old. Increases were largely driven by urban and high volume hospitals.
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Yassi N, Churilov L, Campbell BCV, Sharma G, Bammer R, Desmond PM, Parsons MW, Albers GW, Donnan GA, Davis SM. The association between lesion location and functional outcome after ischemic stroke. Int J Stroke 2015; 10:1270-6. [PMID: 26045301 DOI: 10.1111/ijs.12537] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 02/25/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Infarct location has a critical effect on patient outcome after ischemic stroke, but the study of its role independent of overall lesion volume is challenging. We performed a retrospective, hypothesis-generating study of the effect of infarct location on three-month functional outcome in a pooled analysis of the EPITHET and DEFUSE studies. METHODS Posttreatment MRI diffusion lesions were manually segmented and transformed into standard-space. A novel composite brain atlas derived from three standard brain atlases and encompassing 132 cortical and sub-cortical structures was used to segment the transformed lesion into different brain regions, and calculate the percentage of each region infarcted. Classification and Regression Tree (CART) analysis was performed to determine the important regions in each hemisphere associated with nonfavorable outcome at day 90 (modified Rankin score [mRS] > 1). RESULTS Overall, 152 patients (82 left hemisphere) were included. Median diffusion lesion volume was 37·0 ml, and median baseline National Institutes of Health Stroke Score was 13. In the left hemisphere, the strongest determinants of nonfavorable outcome were infarction of the uncinate fasciculus, followed by precuneus, angular gyrus and total diffusion lesion volume. In the right hemisphere, the strongest determinants of nonfavorable outcome were infarction of the parietal lobe followed by the putamen. CONCLUSIONS Assessment of infarct location using CART demonstrates regional characteristics associated with poor outcome. Prognostically important locations include limbic, default-mode and language areas in the left hemisphere, and visuospatial and motor regions in the right hemisphere.
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Affiliation(s)
- Nawaf Yassi
- Department of Neurology, Melbourne Brain Centre @ Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
| | - Leonid Churilov
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Vic., Australia
| | - Bruce C V Campbell
- Department of Neurology, Melbourne Brain Centre @ Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
| | - Gagan Sharma
- Departement of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
| | - Roland Bammer
- Department of Neurology and Neurological Sciences and Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Patricia M Desmond
- Departement of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
| | - Mark W Parsons
- Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences and Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Geoffrey A Donnan
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Vic., Australia
| | - Stephen M Davis
- Department of Neurology, Melbourne Brain Centre @ Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
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A critical analysis of intra-arterial thrombolytic doses in acute ischemic stroke treatment. Neurocrit Care 2015; 21:119-23. [PMID: 23836425 DOI: 10.1007/s12028-013-9859-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Intra-arterial thrombolytics (IAT) such as Alteplase, Tenecteplase, and Reteplase are currently used in patients with acute ischemic stroke in varying doses. We evaluated the relationship of IA thrombolytic dose with angiographic recanalization, intracerebral hemorrhage (ICH) rates, and clinical outcomes at three comprehensive stroke centers. METHODS We stratified patients who underwent endovascular treatment into tertiles based on intra-arterial thrombolytic dose administered: lower tertile (range 1.5-5 mg), middle tertile (range 6-10 mg), and upper tertile (range 10.3-68.5 mg) of rt-PA equivalent. The rates of angiographic recanalization, ICH, and favorable clinical outcomes (discharge modified Rankin score [mRS] = 0-2) were ascertained and compared within the three tertiles. Logistic regression analyses were performed to determine the association between IA thrombolytic dosages and angiographic recanalization, ICH, and favorable clinical outcomes after adjusting for potential confounders. RESULTS A total of 197 patients were treated with IAT; mean age ±SD was 65.6 ± 16 years; 105 (53.3%) were women. Ninety-one (46.2%) patients received both IVT and IAT. IA rt-PA equivalent dose was not different between the patients with and without ICH [mean (mg) ± SD, 9.8 ± 6.1 versus 9.8 ± 9.5, p = 0.9]. We did not find any relation between increasing doses of IAT (from 2 to 69 mg rt-PA equivalent) and symptomatic or asymptomatic ICH: (p = 0.1630) and (p = 0.6702), respectively. Multivariate analysis demonstrated that IAT dose was not associated with ICH (OR 1.0, 95% CI 0.97-1.07, p = 0.3919) or favorable outcome (OR, 1.00, 95% CI 0.95-1.06, p = 0.7375). In a subset analysis of IVT patients, total doses ranged from 48.2 to 149 mg and were not associated with either symptomatic (p = 0.23) or asymptomatic (p = 0.24) ICHs. CONCLUSION Our study demonstrates that IAT in doses up to 69 mg is safe without any evidence of dose-related ICHs even in those patients who had received IVT.
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Takahashi C, Liang CW, Liebeskind DS, Hinman JD. To Tube or Not to Tube? The Role of Intubation during Stroke Thrombectomy. Front Neurol 2014; 5:170. [PMID: 25295027 PMCID: PMC4172061 DOI: 10.3389/fneur.2014.00170] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 08/22/2014] [Indexed: 01/19/2023] Open
Abstract
In the 10 years since the FDA first cleared the use of endovascular devices for the treatment of acute stroke, definitive evidence that such therapy improves outcomes remains lacking. The decision to intubate patients undergoing stroke thrombectomy impacts multiple variables that may influence outcomes after stroke. Three main areas where intubation may deleteriously affect acute stroke management include the introduction of delays in revascularization, fluctuations in peri-procedural blood pressure, and hypocapnia, resulting in cerebral vasoconstriction. In this mini-review, we discuss the evidence supporting these limitations of intubation during stroke thrombectomy and encourage neurohospitalists, neurocritical care specialists, and neurointerventionalists to carefully consider the decision to intubate during thrombectomy and provide strategies to avoid potential complications associated with its use in acute stroke.
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Affiliation(s)
- Courtney Takahashi
- Department of Neurology and Neurocritical Care, Oregon Health and Science University , Portland, OR , USA
| | - Conrad W Liang
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles , Los Angeles, CA , USA
| | - David S Liebeskind
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles , Los Angeles, CA , USA
| | - Jason D Hinman
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles , Los Angeles, CA , USA
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Abstract
BACKGROUND Most strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred and improve recovery after stroke in some people. Thrombolytic drugs, however, can also cause serious bleeding in the brain, which can be fatal. One drug, recombinant tissue plasminogen activator (rt-PA), is licensed for use in selected patients within 4.5 hours of stroke in Europe and within three hours in the USA. There is an upper age limit of 80 years in some countries, and a limitation to mainly non-severe stroke in others. Forty per cent more data are available since this review was last updated in 2009. OBJECTIVES To determine whether, and in what circumstances, thrombolytic therapy might be an effective and safe treatment for acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched November 2013), MEDLINE (1966 to November 2013) and EMBASE (1980 to November 2013). We also handsearched conference proceedings and journals, searched reference lists and contacted pharmaceutical companies and trialists. SELECTION CRITERIA Randomised trials of any thrombolytic agent compared with control in people with definite ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors applied the inclusion criteria, extracted data and assessed trial quality. We verified the extracted data with investigators of all major trials, obtaining additional unpublished data if available. MAIN RESULTS We included 27 trials, involving 10,187 participants, testing urokinase, streptokinase, rt-PA, recombinant pro-urokinase or desmoteplase. Four trials used intra-arterial administration, while the rest used the intravenous route. Most data come from trials that started treatment up to six hours after stroke. About 44% of the trials (about 70% of the participants) were testing intravenous rt-PA. In earlier studies very few of the participants (0.5%) were aged over 80 years; in this update, 16% of participants are over 80 years of age due to the inclusion of IST-3 (53% of participants in this trial were aged over 80 years). Trials published more recently utilised computerised randomisation, so there are less likely to be baseline imbalances than in previous versions of the review. More than 50% of trials fulfilled criteria for high-grade concealment; there were few losses to follow-up for the main outcomes.Thrombolytic therapy, mostly administered up to six hours after ischaemic stroke, significantly reduced the proportion of participants who were dead or dependent (modified Rankin 3 to 6) at three to six months after stroke (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.78 to 0.93). Thrombolytic therapy increased the risk of symptomatic intracranial haemorrhage (OR 3.75, 95% CI 3.11 to 4.51), early death (OR 1.69, 95% CI 1.44 to 1.98; 13 trials, 7458 participants) and death by three to six months after stroke (OR 1.18, 95% CI 1.06 to 1.30). Early death after thrombolysis was mostly attributable to intracranial haemorrhage. Treatment within three hours of stroke was more effective in reducing death or dependency (OR 0.66, 95% CI 0.56 to 0.79) without any increase in death (OR 0.99, 95% CI 0.82 to 1.21; 11 trials, 2187 participants). There was heterogeneity between the trials. Contemporaneous antithrombotic drugs increased the risk of death. Trials testing rt-PA showed a significant reduction in death or dependency with treatment up to six hours (OR 0.84, 95% CI 0.77 to 0.93, P = 0.0006; 8 trials, 6729 participants) with significant heterogeneity; treatment within three hours was more beneficial (OR 0.65, 95% CI 0.54 to 0.80, P < 0.0001; 6 trials, 1779 participants) without heterogeneity. Participants aged over 80 years benefited equally to those aged under 80 years, particularly if treated within three hours of stroke. AUTHORS' CONCLUSIONS Thrombolytic therapy given up to six hours after stroke reduces the proportion of dead or dependent people. Those treated within the first three hours derive substantially more benefit than with later treatment. This overall benefit was apparent despite an increase in symptomatic intracranial haemorrhage, deaths at seven to 10 days, and deaths at final follow-up (except for trials testing rt-PA, which had no effect on death at final follow-up). Further trials are needed to identify the latest time window, whether people with mild stroke benefit from thrombolysis, to find ways of reducing symptomatic intracranial haemorrhage and deaths, and to identify the environment in which thrombolysis may best be given in routine practice.
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Affiliation(s)
- Joanna M Wardlaw
- University of EdinburghCentre for Clinical Brain SciencesThe Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
| | - Veronica Murray
- Danderyd HospitalDepartment of Clinical Sciences, Karolinska InstitutetStockholmSwedenSE‐182 88
| | - Eivind Berge
- Oslo University HospitalDepartment of Internal MedicineOsloNorwayNO‐0407
| | - Gregory J del Zoppo
- University of WashingtonDepartment of Medicine (Division of Hematology), Department of Neurology325 Ninth AvenueBox 359756SeattleWashingtonUSA98104
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Osaki M, Miyashita F, Koga M, Fukuda M, Shigehatake Y, Nagatsuka K, Minematsu K, Toyoda K. Simple clinical predictors of stroke outcome based on National Institutes of Health Stroke Scale score during 1-h recombinant tissue-type plasminogen activator infusion. Eur J Neurol 2013; 21:411-8. [DOI: 10.1111/ene.12294] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 09/23/2013] [Indexed: 11/30/2022]
Affiliation(s)
- M. Osaki
- Department of Cerebrovascular Medicine; National Cerebral and Cardiovascular Center; Osaka Japan
| | - F. Miyashita
- Department of Cerebrovascular Medicine; National Cerebral and Cardiovascular Center; Osaka Japan
| | - M. Koga
- Division of Stroke Care Unit; National Cerebral and Cardiovascular Center; Osaka Japan
| | - M. Fukuda
- Department of Cerebrovascular Medicine; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Y. Shigehatake
- Department of Cerebrovascular Medicine; National Cerebral and Cardiovascular Center; Osaka Japan
| | - K. Nagatsuka
- Department of Neurology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - K. Minematsu
- Department of Cerebrovascular Medicine; National Cerebral and Cardiovascular Center; Osaka Japan
| | - K. Toyoda
- Department of Cerebrovascular Medicine; National Cerebral and Cardiovascular Center; Osaka Japan
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Pancioli AM, Adeoye O, Schmit PA, Khoury J, Levine SR, Tomsick TA, Sucharew H, Brooks CE, Crocco TJ, Gutmann L, Hemmen TM, Kasner SE, Kleindorfer D, Knight WA, Martini S, McKinney JS, Meurer WJ, Meyer BC, Schneider A, Scott PA, Starkman S, Warach S, Broderick JP. Combined approach to lysis utilizing eptifibatide and recombinant tissue plasminogen activator in acute ischemic stroke-enhanced regimen stroke trial. Stroke 2013; 44:2381-7. [PMID: 23887841 DOI: 10.1161/strokeaha.113.001059] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In a previous study, 0.3 and 0.45 mg/kg of intravenous recombinant tissue plasminogen activator (rt-PA) were safe when combined with eptifibatide 75 mcg/kg bolus and a 2-hour infusion (0.75 mcg/kg per minute). The Combined Approach to Lysis Utilizing Eptifibatide and rt-PA in Acute Ischemic Stroke-Enhanced Regimen (CLEAR-ER) trial sought to determine the safety of a higher-dose regimen and to establish evidence for a phase III trial. METHODS CLEAR-ER was a multicenter, double-blind, randomized safety study. Ischemic stroke patients were randomized to 0.6 mg/kg rt-PA plus eptifibatide (135 mcg/kg bolus and a 2-hour infusion at 0.75 mcg/kg per minute) versus standard rt-PA (0.9 mg/kg). The primary safety end point was the incidence of symptomatic intracranial hemorrhage within 36 hours. The primary efficacy outcome measure was the modified Rankin Scale (mRS) score ≤1 or return to baseline mRS at 90 days. Analysis of the safety and efficacy outcomes was done with multiple logistic regression. RESULTS Of 126 subjects, 101 received combination therapy, and 25 received standard rt-PA. Two (2%) patients in the combination group and 3 (12%) in the standard group had symptomatic intracranial hemorrhage (odds ratio, 0.15; 95% confidence interval, 0.01-1.40; P=0.053). At 90 days, 49.5% of the combination group had mRS ≤1 or return to baseline mRS versus 36.0% in the standard group (odds ratio, 1.74; 95% confidence interval, 0.70-4.31; P=0.23). After adjusting for age, baseline National Institutes of Health Stroke Scale, time to intravenous rt-PA, and baseline mRS, the odds ratio was 1.38 (95% confidence interval, 0.51-3.76; P=0.52). CONCLUSIONS The combined regimen of intravenous rt-PA and eptifibatide studied in this trial was safe and provides evidence that a phase III trial is warranted to determine efficacy of the regimen. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00894803.
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Affiliation(s)
- Arthur M Pancioli
- Department of Emergency Medicine, University of Cincinnati Neuroscience Institute, Cincinnati, OH, USA.
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Sucharew H, Khoury J, Moomaw CJ, Alwell K, Kissela BM, Belagaje S, Adeoye O, Khatri P, Woo D, Flaherty ML, Ferioli S, Heitsch L, Broderick JP, Kleindorfer D. Profiles of the National Institutes of Health Stroke Scale items as a predictor of patient outcome. Stroke 2013; 44:2182-7. [PMID: 23704102 DOI: 10.1161/strokeaha.113.001255] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Initial National Institutes of Health Stroke Scale (NIHSS) score is highly predictive of outcome after ischemic stroke. We examined whether grouping strokes by presence of individual NIHSS symptoms could provide prognostic information additional or alternative to the NIHSS total score. METHODS Ischemic strokes from the Greater Cincinnati Northern Kentucky Stroke Study in 2005 were used to develop the model. Latent class analysis was implemented to form groups of patients with similar retrospective NIHSS (rNIHSS) item responses. Profile group was then used as an independent predictor of discharge modified Rankin and mortality, using logistic regression and Cox proportional hazards model. RESULTS A total of 2112 stroke patients were identified in 2005. Six distinct profiles were characterized. Consistent with the profile patterns, the median rNIHSS total score decreased from profile A "most severe" (median [interquartile range], 20 [15-25]) to profile F "mild" (1[1-2]). Two profiles falling between these extremes, C and D, both had median rNIHSS total score of 5, but different survival rates. Compared with A, C was associated with 59% risk reduction for death, whereas D with 70%. C patients were more likely to have decreased level of consciousness and abnormal language, whereas D patients were more likely to have abnormal right arm and right leg motor function. CONCLUSIONS Six rNIHSS profiles were identifiable using latent class analysis. In particular, 2 symptom profiles with identical median rNIHSSS were observed with widely disparate outcomes, which may prove useful both clinically and for research studies as an enhancement to the overall NIHSS score.
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Affiliation(s)
- Heidi Sucharew
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA.
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Park JH, Park SK, Jang KS, Jang DK, Han YM. Critical use of balloon angioplasty after recanalization failure with retrievable stent in acute cerebral artery occlusion. J Korean Neurosurg Soc 2013; 53:77-82. [PMID: 23560170 PMCID: PMC3611063 DOI: 10.3340/jkns.2013.53.2.77] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 11/13/2012] [Accepted: 02/04/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Sudden major cerebral artery occlusion often resists recanalization with currently available techniques or can results in massive symptomatic intracranial hemorrhage (sICH) after thrombolytic therapy. The purpose of this study was to examine mechanical recanalization with a retrievable self-expanding stent and balloon in acute intracranial artery occlusions. METHODS Twenty-eight consecutive patients with acute intracranial artery occlusions were treated with a Solitaire retrievable stent. Balloon angioplasty was added if successful recanalization was not achieved after stent retrieval. The angiographic outcome was assessed by Thrombolysis in Cerebral Infarction (TICI) and the clinical outcomes were assessed by the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS). RESULTS At baseline, mean age was 69.4 years and mean initial NIHSS score was 12.5. A recanalization to TICI 2 or 3 was achieved in 24 patients (85%) after stent retrieval. Successful recanalization was achieved after additional balloon angioplasty in 4 patients. At 90-day follow-up, 24 patients (85%) had a NIHSS improvement of ≥4 and 17 patients (60%) had a good outcome (mRS ≤2). Although there was sICH, there was one death associated with the procedure. CONCLUSION Mechanical thromboembolectomy with a retrievable stent followed by additional balloon angioplasty is a safe and effective first-line therapy for acute intracranial artery occlusions especially in case of unsuccessful recanalization after stent thrombectomy.
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Affiliation(s)
- Jae Hyun Park
- Department of Neurosurgery, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
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Zaidat OO, Liebeskind DS, Edgell RC, Amlie-Lefond CM, Kalia JS, Alexandrov AV. Clinical trial design for endovascular ischemic stroke intervention. Neurology 2012; 79:S221-33. [PMID: 23008403 DOI: 10.1212/wnl.0b013e31826992cf] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Randomized, double-blinded, placebo-controlled trials have significant impact on clinical practice. The ultimate goal of a clinical trial of therapy for acute ischemic stroke (AIS) is to compare 2 interventions. Challenges may include interventional therapy standardization, enrollment rate, patient selection, biases, data and safety monitoring, reporting, and financial and logistical support. METHOD Selected randomized and single-arm prospective AIS trial designs. Clinical trial elements and their challenges are reviewed. Innovative designs and proposed recommendations to overcome some of the specific challenges and limitations are discussed. RESULTS AIS therapy trials have specific challenges related to ethical issues, enrollment rate, outcome measures, limited time to treatment, efficacy, safety, and limited or variable operator experience with complex technology in a delicate end organ. Proposed suggestions for improving trial design include the following: incorporation of a lead-in phase; careful patient and outcome measure selection; historical, concurrent, or hybrid controls; open data access; and a Bayesian approach. An open data paradigm may facilitate creation of computerized prediction models for future trials (minimizing cost by decreasing sample size or providing futility analyses and directing resources to other trials). Collaborative, consortium, and network infrastructures may allow more effective and efficient study completion. Self-learning, self-correcting trials with intrinsic flexibility to adapt may help future clinical trial design in AIS. CONCLUSION The randomized clinical trial design in AIS endovascular therapy is challenging. Lead-in phases, careful patient selection, use of innovative outcome measures, control groups, and newer clinical trial design may enhance conduct of future trials, their validity, and their results.
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Affiliation(s)
- Osama O Zaidat
- Department of Neurology, Medical College of Wisconsin and Froedtert Hospital, Milwaukee, WI, USA.
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Hassan AE, Chaudhry SA, Miley JT, Khatri R, Hassan SA, Suri MFK, Qureshi AI. Microcatheter to recanalization (procedure time) predicts outcomes in endovascular treatment in patients with acute ischemic stroke: when do we stop? AJNR Am J Neuroradiol 2012; 34:354-9. [PMID: 22821922 DOI: 10.3174/ajnr.a3202] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular treatment for acute ischemic stroke consists of various mechanical and pharmacologic modalities used for recanalization of arterial occlusions. We performed this study to determine the relationship among procedure time, recanalization, and clinical outcomes in patients with acute ischemic stroke undergoing endovascular treatment. MATERIALS AND METHODS We analyzed data from consecutive patients with acute ischemic stroke who underwent endovascular treatment during a 6-year period. Demographic characteristics, NIHSS score before and 24 hours after the procedure, and discharge mRS score were ascertained. Procedure time was defined by the time interval between microcatheter placement and recanalization or completion of the procedure. We estimated the procedure time after which favorable clinical outcome was unlikely, even after adjustment for age, time from symptom onset, and admission NIHSS scores. RESULTS We analyzed 209 patients undergoing endovascular treatment (mean age, 65 ± 16 years; 109 [52%] men; mean admission/preprocedural NIHSS score, 15.3 ± 6.8). Complete or partial recanalization was observed in 176 (84.2%) patients, while unfavorable outcome (mRS 3-6) was observed in 138 (66%) patients at discharge. In univariate analysis, patients with procedure time ≤30 minutes had lower rates of unfavorable outcome at discharge compared with patients with procedure time ≥30 minutes (52.3% versus 72.2%, P = .0049). In our analysis, the rates of favorable outcomes in endovascularly treated patients after 60 minutes were lower than rates observed with placebo treatment in the Prourokinase for Acute Ischemic Stroke Trial. In logistic regression analysis, unfavorable outcome was positively associated with age (P = .0012), admission NIHSS strata (P = .0017), and longer procedure times (P = .0379). CONCLUSIONS Procedure time in patients with acute ischemic stroke appears to be a critical determinant of outcomes following endovascular treatment. This highlights the need for procedure time guidelines for patients being considered for endovascular treatment in acute ischemic stroke.
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Affiliation(s)
- A E Hassan
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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Qureshi AI, Chaudhry SA, Sapkota BL, Rodriguez GJ, Suri MFK. Discharge destination as a surrogate for Modified Rankin Scale defined outcomes at 3- and 12-months poststroke among stroke survivors. Arch Phys Med Rehabil 2012; 93:1408-1413.e1. [PMID: 22446290 DOI: 10.1016/j.apmr.2012.02.032] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 02/20/2012] [Accepted: 02/24/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the predictive value of discharge destination as a surrogate for defining unfavorable outcome at 3- and 12-months poststroke. DESIGN Analysis of the prospectively collected data from a randomized, placebo-controlled trial in patients with ischemic stroke presenting within 3 hours of symptom onset. SETTING Post hoc analysis of patients recruited in a clinical trial. PARTICIPANTS Patients (N=530) discharged alive from the hospital after ischemic stroke. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Positive and negative predictive value and likelihood ratios of discharge destination for unfavorable outcome at 3- and 12-months poststroke defined by a Modified Rankin Scale (MRS) score of 2 to 6, 3 to 6, or 4 to 6. A likelihood ratio indicates how many times more (or less) likely a particular discharge destination is seen in patients with an unfavorable outcome compared with those without unfavorable outcome. RESULTS The positive predictive value of nursing home and rehabilitation facility discharges was highest for unfavorable outcome defined by an MRS score of 2 to 6 (95%) and rehabilitation facility (89%) at 3-months poststroke, respectively. The positive predictive value of rehabilitation facility/nursing home (90%) was also highest for unfavorable outcomes defined by an MRS score of 2 to 6 compared with those defined by MRS scores of 3 to 6 (79%) and 4 to 6 (57%). The positive likelihood ratio was highest for nursing home discharges (13; 95% confidence interval [CI], 4.1-41) followed by rehabilitation facility discharges for unfavorable outcome defined by an MRS score of 2 to 6 at 3-months poststroke (5.3; 95% CI, 3.5-7.9). The negative likelihood ratio was the highest for home discharge for unfavorable outcome defined by an MRS score of 2 to 6 (4.5; 95% CI, 3.4-6.1). A similar pattern was observed with unfavorable outcome defined using various thresholds at 12 months. CONCLUSIONS Discharge destination can provide high predictive values and likelihood ratios for death and disability at 3-months poststroke, as defined by an MRS of score of 2 to 6.
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Affiliation(s)
- Adnan I Qureshi
- Dept of Neurology, University of Minnesota, 12-100 PWB, 516 Delaware St SE, Minneapolis, MN 55455, USA.
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Abstract
Computed tomographic perfusion (CTP) imaging is an advanced modality that provides important information about capillary-level hemodynamics of the brain parenchyma. CTP can aid in diagnosis, management, and prognosis of acute stroke patients by clarifying acute cerebral physiology and hemodynamic status, including distinguishing severely hypoperfused but potentially salvageable tissue from both tissue likely to be irreversibly infarcted ("core") and hypoperfused but metabolically stable tissue ("benign oligemia"). A qualitative estimate of the presence and degree of ischemia is typically required for guiding clinical management. Radiation dose issues with CTP imaging, a topic of much current concern, are also addressed in this review.
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Affiliation(s)
- Angelos A Konstas
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Shobha N, Bhatia R, Boyko M, Tymchuk S, Kumarpillai G, Smith E, Demchuk AM. Outcomes in Acute Ischemic Strokes Presenting with Disabling Neurologic Deficits without Intracranial Vascular Occlusion. Int J Stroke 2011; 6:392-7. [DOI: 10.1111/j.1747-4949.2011.00607.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background Patients with moderate to severe acute ischemic stroke without intracranial vessel occlusion are an intriguing subset of stroke patients. They pose diagnostic and therapeutic challenges to the physician. We sought to study these patients with an emphasis on their radiological and clinical outcomes. Methods This is a retrospective cohort study of ischemic stroke patients (NIHSS ≥ 6), with no intracranial vessel occlusion on computed tomography angiography within six-hours of symptom onset. Follow-up imaging – either computed tomography brain or magnetic resonance imaging – was performed within one- to seven-days. The primary outcome was modified Rankin Scale score ≤ 2 at three-months. Results In a database of 1308 patients, we identified 99 (7·6%) patients with NIHSS≥6 and no intracranial vessel occlusion on computed tomography angiography. The mean age was 67·8 ± 15·4 years and 60 (60·6%) were men. The median baseline NIHSS was nine (6–28). The initial computed tomography head was normal in 79 (79·8%) patients. Dramatic early clinical improvement at 24 h (NIHSS score ≤2 at 24 h or change between baseline and 24 h NIHSS score 15 points) was seen in 38 (38·4%) patients. Follow-up scans showed infarcts in 66 (66·7%) patients. Fifty (50·5%) patients received tissue plasminogen activator; one (2%) tissue plasminogen activator-treated patient developed symptomatic intracranial hemorrhage. At three-months; 59 (59·6%) patients were independent (modified Rankin Scale ≤2), 34 (34·3%) patients were dependent (modified Rankin Scale 3–5), and six (6·1%) were dead. The factors associated with the unlikelihood of good outcome were higher initial NIHSS (odds ratio 0·86 per additional point, 95% confidence interval 0·77–0·95, P = 0·003), and older age (odds ratio 0·95 per additional year, 95% confidence interval 0·92–0·98, P = 0·004). Conclusion Stroke without intracranial occlusions are not a benign entity. Factors that are independently associated with decreased likelihood of a good outcome are higher baseline NIHSS, and older age. Treatment with tissue plasminogen activator is not a predictor of outcome.
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Affiliation(s)
- Nandavar Shobha
- Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Rohit Bhatia
- Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Boyko
- Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Sarah Tymchuk
- Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Gopukumar Kumarpillai
- Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Eric Smith
- Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Calgary Stroke Program, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Andrew M. Demchuk
- Department of Clinical Neurosciences, Calgary Stroke Program, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Calgary Stroke Program, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
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Zacharatos H, Hassan AE, Vazquez G, Hussein HM, Rodriguez GJ, Suri MFK, Lakshminarayan K, Ezzeddine MA, Qureshi AI. Comparison of acute nonthrombolytic and thrombolytic treatments in ischemic stroke patients 80 years or older. Am J Emerg Med 2011; 30:158-64. [PMID: 21247724 DOI: 10.1016/j.ajem.2010.11.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 11/10/2010] [Accepted: 11/14/2010] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The aim of this study was to compare the clinical outcomes of acute ischemic stroke patients 80 years or older treated with intravenous recombinant tissue plasminogen activator (i.v. rt-PA), or endovascular intervention with or without i.v. rt-PA, or nonthrombolytic medical treatment. METHODS This study was a retrospective, nonrandomized, observational study of patients, admitted within 9 hours of symptom onset, at 3 academic, university-affiliated hospitals. The main outcome measures were neurologic improvement, defined by improvement in National Institutes of Health Stroke Scale score at 7 days or discharge of 4 or more, or achieving a score of 0; symptomatic and asymptomatic intracerebral hemorrhage; favorable outcome (discharge modified Rankin score 0-2); and in-hospital mortality. RESULTS A total of 44 patients received i.v. rt-PA, 46 received endovascular intervention with or without i.v. rt-PA, and 66 received nonthrombolytic medical treatment. I.v. rt-PA-treated patients had a significantly clinically higher chance of favorable outcome (odds ratio [OR], 5.6; 95% confidence interval [CI], 1.8-17.5), when compared with nonthrombolytic medical treatment. A significantly higher rate of neurologic improvement was observed among the i.v. rt-PA (7.2; 95% CI, 2.7-19.5) and endovascularly treated patients (5.8; 95% CI, 2-16.8) when compared with nonthrombolytic medical treatment. CONCLUSIONS A prominently higher rate of neurologic improvement and favorable clinical outcome was observed among acute ischemic stroke patients 80 years or older treated with i.v. rt-PA or endovascular intervention when compared with nonthrombolytic medical treatment, supporting the use of acute thrombolytic therapies in this patient population when contraindications are not present.
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Affiliation(s)
- Haralabos Zacharatos
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, MN 55455, USA
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Adams HP. Clinical Scales to Assess Patients with Stroke. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Brown W, Al-Khoury L, Tafreshi G, Lyden PD. Intravenous Thrombolysis. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10049-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Meiner Z, Sajin A, Schwartz I, Tsenter J, Yovchev I, Eichel R, Ben-Hur T, Leker RR. Rehabilitation outcomes of stroke patients treated with tissue plasminogen activator. PM R 2010; 2:698-702; quiz 792. [PMID: 20709299 DOI: 10.1016/j.pmrj.2010.04.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Revised: 04/24/2010] [Accepted: 05/18/2010] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate the influence of thrombolysis on functional outcomes after rehabilitation. BACKGROUND Systemic thrombolysis with tissue plasminogen activator (tPA) is considered the mainstay of acute stroke therapy and was found to improve short-term outcome. DESIGN Matched case-controlled design. SETTING Inpatient neurology and rehabilitation departments. PARTICIPANTS Thirty-seven patients given tPA and 37 control patients not treated with lytics because of protocol limits. METHODS We retrospectively analyzed data from a cohort of stroke patients who were treated with systemic tPA. The rehabilitation outcome of thrombolysis-treated patients was compared with that observed for tPA-ineligible and age- and stroke severity-matched patients treated at the same neurology and rehabilitation departments. MAIN OUTCOME MEASURE Neurological evaluation was assessed with the National Institutes of Health stroke scale (NIHSS). Activity of daily living was measured using the Functional Independence Measure (FIM) instrument. Functional outcome was measured using the modified Rankin scale (mRS). RESULTS The treatment group included 37 patients given tPA; 37 tPA-ineligible patients served as controls. On admission to rehabilitation, there were no significant differences in functional, neurological, and rehabilitation parameters between the groups. At the end of the rehabilitation period, NIHSS scores were significantly lower in the thrombolysis group (P = .036). More patients in the thrombolysis group reached functional independence defined as mRS < or =2 (20/37 versus 10/37; P = .03). At the end of rehabilitation, total FIM score (mean 102.8 versus 93.9; P = .039), total FIM gain (mean 27.8 versus 21.4; P = .09), and total FIM efficiency scores (0.8 versus 0.43; P = .013) were higher in the thrombolysis group and more patients in this group were discharged home. CONCLUSIONS Although the bulk of neurological improvement occurred before the inpatient rehabilitation, thrombolysis-treated patients continue to improve faster and to a larger extent during the rehabilitation period suggesting that the beneficial effects of thrombolysis continue beyond the acute phase.
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Affiliation(s)
- Zeev Meiner
- Department of Physical Medicine, POB 24035, Hadassah-Hebrew University Medical Center, Jerusalem, 91240 Israel.
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