Quantifying the value of stroke disability outcomes: WHO global burden of disease project disability weights for each level of the modified Rankin Scale

Endovascular Treatment of Acute Large Vessel Occlusion in the Anterior and Posterior Circulation

Endovascular treatment (EVT) has been strongly recommended as a first-line treatment for acute ischemic strokes (AIS) caused by large vessel occlusion (LVO). To evaluate the efficacy, safety, and predictors of favorable outcomes of EVT for LVO-caused AIS in both the anterior and posterior circulations, consecutive patients who had undergone EVT for AISs caused by LVO were retrospectively enrolled, and the clinical data, symptomatic intracranial hemorrhage (sICH), modified Rankin Scale (mRS) score, and mortality at 90 days were analyzed. In total, 231 patients were enrolled with a mean age of 63.25 ± 11.48 years, including 167 (72.29%) patients with anterior circulation occlusion (ACO) and 64 (27.71%) patients with posterior circulation occlusion (PCO) treated with EVT. The median baseline National Institutes of Health Stroke Scale (NIHSS) Score on admission was 17 (12-20). The median time from symptom onset to recanalization (OTR) was 380 (307.5-461) minutes. Successful recanalization was achieved in 90.04% of patients. At 3-month follow-up, 118 (51.08%) patients had favorable clinical outcomes (mRS 0-2), with a mortality rate of 18.61% (43/231). Younger age (p = 0.001), a lower baseline NIHSS score (p < 0.001), a higher recanalization rate (p = 0.018), and shorter OTR time (p = 0.026) were significant independent risk factors for favorable outcomes. Compared to patients with ACO, PCO patients had a lower favorable outcome rate (p = 0.049) and a higher mortality rate (p < 0.001). In conclusion, EVT is safe and effective for patients with LVO-caused AIS, and younger age, lower baseline NIHSS scores, a higher recanalization rate, and shorter OTR time are independent risk factors for favorable outcomes. PCO patients may have worse clinical outcomes and a higher mortality rate than ACO patients.

Novel Risk Score to Predict Poor Outcome After Endovascular Treatment in Anterior Circulation Occlusive Acute Ischemic Stroke

BACKGROUND

We aimed to develop and validate a prognostic score to predict outcomes after endovascular treatment in acute ischemic stroke.

METHODS

The prognostic score was developed based on the ACTUAL (Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke) registry. The validation cohort was derived from the Captor trial. Independent predictors of poor outcome after endovascular treatment were obtained from the least absolute shrinkage and selection operator regression and multivariable logistic regression. Corresponding regression coefficients were used to generate point scoring system. The area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test were used to assess model discrimination and calibration. The predictive properties of the developed prognostic score were validated and the discriminative power was compared with other validated tools.

RESULTS

A 17-point Age, Collateral Status, Blood glucose, Alberta Stroke Program Early Computed Tomography Score, and National Institutes of Health Stroke Scale score scale was developed from the set of independent predictors, including age, admission National Institutes of Health Stroke Scale score, Alberta Stroke Program Early Computed Tomography Score on initial computed tomography scan, blood glucose, and collateral status. The scale showed good discrimination in the derivation cohort (area under the receiver operating characteristic curve, 0.79 [95% CI, 0.75-0.82]) and validation cohorts (area under the receiver operating characteristic curve, 0.77 [95% CI, 0.70-0.84]). The scale was well calibrated (Hosmer-Lemeshow test) in the derivation cohort (P=0.57) and validation cohort (P=0.75).

CONCLUSIONS

The Age, Collateral Status, Blood glucose, Alberta Stroke Program Early Computed Tomography score, and National Institutes of Health Stroke Scale score scale is a valid tool for predicting outcomes and may be useful for endovascular stroke treatment in anterior circulation large vessel occlusions.

Endovascular thrombectomy in acute stroke with a large ischemic core: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Endovascular thrombectomy (EVT) is the standard treatment for acute ischemic stroke due to internal carotid artery (ICA) or middle cerebral artery (MCA) M1 occlusion with a small ischemic core. However, the effect of EVT on acute stroke with a large ischemic core remains unclear. This study aimed to evaluate the association of EVT plus medical care versus medical care alone with outcomes in patients with acute stroke and a large ischemic core due to ICA or MCA M1 occlusion.

METHODS AND FINDINGS

PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from January 1, 2000 to September 25, 2024. There were no language restrictions. Randomized controlled trials (RCTs) of patients with acute stroke and a large ischemic core that compared EVT plus medical care versus medical care alone were evaluated. We computed the random-effects estimate based on the inverse variance method. Risk ratio (RR) with 95% confidence interval (CI) was used to measure outcomes of EVT plus medical care versus medical care alone. The primary outcome was functional independence, defined as modified Rankin Scale (mRS) of 0-2 at 90 days post-stroke; and the lead secondary outcome was reduced disability, defined as ordinal shift of mRS. Safety outcomes were requiring constant care or death (mRS 5-6), death, and early symptomatic intracranial hemorrhage (sICH). Grading of Recommendations Assessment, Development and Evaluations (GRADE) was used to evaluate summaries of evidence for the outcomes. We included six RCTs comprising 1870 patients (826 females [44.2%]) with acute stroke and a larger moderate or large ischemic core due to ICA or MCA M1 occlusion. All patients were nondisabled before stroke. Pooled results showed that at 90 days post-stroke, EVT plus medical care, compared with medical care alone, was associated with greater functional independence (RR 2.53, 95% CI [1.95, 3.29]; p  < 0.001; number needed to treat [NNT], 9, 95% CI [6,15]) and reduced disability (common odds ratio 1.63, 95% CI [1.38, 1.93]; p < 0.001; NNT, 4 [minimum possible NNT, 2; maximum possible NNT, 6]). EVT plus medical care, compared with medical care alone, was associated with a lower risk of requiring constant care or death (RR 0.74, 95% CI [0.66, 0.84]; p  <  0.001; NNT, 7, 95% CI [6,11]). EVT plus medical care, compared with medical care alone, was associated with a nonsignificantly higher proportion of patients with early symptomatic intracranial hemorrhage (RR 1.65, 95% CI [1.00, 2.70]; p  =  0.05). The rates of death were not significantly different between the EVT plus medical care and medical care alone groups (RR 0.86, 95% CI [0.72, 1.02]; p  =  0.08). Main limitations include variability in imaging definitions of large core and inclusion of both larger moderate and large cores in the analysis.

CONCLUSIONS

Among patients with acute stroke and a larger moderate or large ischemic core due to ICA or MCA M1 occlusion who were nondisabled before stroke, EVT plus medical care, compared with medical care alone, may be associated with improved functional independence, reduced disability, and reduced rates of severe disability or death at 90 days post-stroke. PROSPERO registration number: CRD42024514605.

Treatment outcome of bridge mechanical thrombectomy with different IV-tPA dosages in the standard and extended time window in real-world practice

BACKGROUND

Differences of treatment outcome between full or reduced dose of tissue plasminogen activator (tPA) for bridge mechanical thrombectomy (MT) in the extended time window have not been clearly established. We aimed to present real-world results of bridge MT with different tPA dosages in the standard and extended windows.

MATERIALS AND METHODS

Patients with anterior circulation stroke treated with MT between 2017 and 2021 at two stroke referral centers were retrospectively reviewed. Bridge MT with tPA were categorized as full (0.9 mg/kg) or reduced (<0.9 mg/kg) dose. Standard window (SW) cohort was defined as MT performed within 6 h of acute ischemic stroke onset, while those beyond 6 h as the extended window (EW) cohort. 90 days Modified Rankin Scale (mRS) score, technical treatment success, in-hospital mortality, and post-treatment hemorrhage were analyzed.

RESULTS

A total of 423 patients met the inclusion criteria, 218 of which treated in the SW, while 205 treated in the EW. Within the SW cohort, the full-dose tPA group demonstrated a higher proportion of good functional outcome (GFO) at 90 days (mRS0-3) versus reduced (49% vs 21%, p = 0.0358). The overall GFO of SW was higher than that of the EW cohort (33% vs 20%, p = 0.0480). Within the EW cohort, GFO was similar between full and reduced dose groups. Successful reperfusion rate was lower in SW versus EW cohorts (39% vs 58%, p = 0.0199).

CONCLUSION

In real-world practice, the GFO of bridge MT is better than MT alone. The tPA dosage is not a determining factor of GFO in EW MT.

Endovascular versus Best Medical Treatment for Acute Carotid Occlusion BelOw Circle of Willis (ACOBOW): The ACOBOW Study

Background Symptomatic acute occlusions of the internal carotid artery (ICA) below the circle of Willis can cause a variety of stroke symptoms, even if the major intracranial cerebral arteries remain patent; however, outcome and safety data are limited. Purpose To compare treatment effects and procedural safety of endovascular treatment (EVT) and best medical treatment (BMT) in patients with symptomatic acute occlusions of the ICA below the circle of Willis. Materials and Methods This retrospective, multicenter cohort study from 22 comprehensive stroke centers in Europe and Asia includes patients treated between January 1, 2008, and December 31, 2022. Functional (modified Rankin Scale [mRS]) and clinical (National Institutes of Health Stroke Scale [NIHSS]) outcomes, safety measures (symptomatic intracerebral hemorrhage), mortality, and procedural complications were assessed. Results A total 354 patients met the inclusion criteria (median age, 72 years [IQR, 60-81 years]; median NIHSS, 13 [IQR, 7-19]). Most frequent occlusions were in the C1 segment (243 of 354; 68.6%). Of 354 patients, 82.2% (291 patients) were administered EVT. In the overall population, favorable outcomes (mRS 0-2), mortality, and symptomatic intracerebral hemorrhage occurred in 40.6% (108 of 266 patients), 25.2% (67 of 266 patients), and 7.1% (25 of 350 patients), respectively. After adjustment, no statistically significant difference in functional outcome was observed (adjusted odds ratio [AOR], 0.82 [95% CI: 0.31, 2.12]; average treatment effect, -12.7%; P = .19) in the EVT compared with BMT group. Symptomatic intracerebral hemorrhage (average treatment effect, -0.28%; P = .95) and mortality did not differ between both groups (average treatment effect, -17.1%; P = .07). EVT resulted in complete recanalization of the occlusion in 80.9% (229 of 283) of cases. Periprocedural distal embolization occurred in 27.8% (81 of 291 patients) and was associated with poor outcomes (AOR, 0.41; 95% CI: 0.18, 0.93; P = .03). Conclusion EVT did not reveal a favorable treatment effect over BMT, and both therapies were safe. EVT had a risk for periprocedural distal embolization associated with poor outcomes. © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Daou and Chaudhary in this issue.

Association between patient-reported frailty and nonhome discharge among older patients with acute stroke: A prospective study

OBJECTIVE

To investigate the association between prestroke frailty and nonhome discharge, prolonged length of stay as well as functional outcomes.

DESIGN

Prospective observational study.

SETTING

Single urban teaching hospital in Guangzhou, China.

PARTICIPANTS

Consecutive sample of 271 older patients admitted with acute stroke.

INTERVENTION

N/A.

MAIN MEASURES

A five-item FRAIL scale (0∼5 points) and the stroke severity at onset were measured. The primary outcome of interest was nonhome discharge, with secondary outcomes including prolonged length of stay and worse short-term prognosis. Multivariable logistic regression adjusting for confounding factors was used to determine the association between patient-reported frailty and nonhome discharge, prolonged length of stay, worse short-term prognosis.

RESULTS

The population had a median age of 68 [interquartile range (IQR), 64∼74)]years, with 50 individuals (18.5%) identified as frail. After adjusting for age, sex, Barthel index, National Institutes of Health Stroke Scale, and Mini-Mental Status Exam score at admission, patients with self-reported frailty were significantly likely to experience nonhome discharge (Odds Ratio [OR] = 4.788; 95% confidence interval [CI] = 1.272∼18.017; p = .021), prolonged length of stay (OR = 4.76; 95% CI = 1.80∼12.56; p = .002), mRS scores at 30 days (OR = 6.72;95% CI = 1.79∼25.20; p = .005) and three months postdischarge and three-month (OR = 8.94; 95% CI = 2.10∼38.08; p = .003).

CONCLUSIONS

In older adults with stroke, frailty is associated with nonhome discharge, prolonged length of stay, and worse short-term prognosis, regardless of the stroke severity, cognition, and Barthel index score at admission. FRAIL scale can be used as a practical screening tool in acute care setting by multidisciplinary team in supporting discharge process.

Combined Selective Endovascular Brain Hypothermia with Edaravone Dexborneol versus Edaravone Dexborneol Alone for Endovascular Treatment in Acute Ischemic Stroke (SHE): Protocol for a Multicenter, Single-Blind, Randomized Controlled Study

INTRODUCTION

Selective endovascular brain hypothermia has been proposed as a potential neuroprotective strategy; however, its effectiveness is still not well established. The primary objective of this trial is to investigate the efficacy and safety of selective endovascular brain hypothermia with edaravone dexborneol for endovascular treatment in acute ischemic stroke (AIS).

METHODS

The SHE study is a multicenter, single-blind, randomized controlled clinical trial. Patients with acute anterior circulation ischemic stroke who received endovascular treatment within 24 h after stroke onset and achieved successful recanalization will be enrolled and centrally randomized into combined selective endovascular brain hypothermia with edaravone dexborneol or edaravone dexborneol alone groups in a 1:1 ratio (n = 564). Patients allocated to the hypothermia group will receive 300 mL cool saline at 4°C through guiding catheter (30 mL/min) into target vessel within 3 min after recanalization and then receive edaravone dexborneol (edaravone dexborneol 15 mL + NS 100 mL ivgtt bid for 10-14 days) within 24 h after admission. The control group will receive 300 mL 37°C saline (30 mL/min) infused into target vessel through guiding catheter and then receive edaravone dexborneol. All patients enrolled will receive standard care according to current guidelines for stroke management. The primary outcome is the proportion of functional independence, defined as a mRS score of 0-2 at 90 days after randomization.

CONCLUSION

This is a randomized clinical trial with a large sample size to compare combined selective endovascular brain hypothermia and edaravone dexborneol with edaravone dexborneol alone in patients with acute anterior ischemic stroke. The SHE trial aims to provide further evidence of the benefit of selective endovascular brain hypothermia in AIS patients who received endovascular treatment.

Thrombectomy for Stroke With Large Infarct on Noncontrast CT: The TESLA Randomized Clinical Trial

Importance

Recent large infarct thrombectomy trials used heterogeneous imaging modalities and time windows for patient selection. Noncontrast computed tomographic (CT) scan is the most common stroke imaging approach. It remains uncertain whether thrombectomy is effective for patients with large infarcts identified using noncontrast CT alone within 24 hours of stroke onset.

Objective

To evaluate the effect of thrombectomy in patients with a large infarct on a noncontrast CT scan within 24 hours of onset.

Design, Setting, and Participants

Open-label, blinded-end point, bayesian-adaptive randomized trial with interim analyses for early stopping (futility or success) or population enrichment, which was conducted at 47 US academic and community-based stroke thrombectomy centers. Three hundred patients presenting within 24 hours with anterior-circulation, large-vessel occlusion and large infarct on noncontrast CT scan, with Alberta Stroke Program Early CT Scores of 2 to 5, were randomized to undergo thrombectomy or usual care. Enrollment occurred July 16, 2019 to October 17, 2022; final follow-up, January 25, 2023.

Intervention

The intervention patients (n = 152) underwent endovascular treatment using standard thrombectomy devices and usual medical care. Control patients (n = 148) underwent usual medical care alone.

Main Outcomes and Measures

The primary efficacy end point was improvement in 90-day functional outcome measured using mean utility-weighted modified Rankin Scale (UW-mRS) scores (range, 0 [death or severe disability] to 10 [no symptoms]; minimum clinically important difference, 0.3). A bayesian model determined the posterior probability that the intervention would be superior to usual care; statistical significance was a 1-sided posterior probability of .975 or more. The primary adverse event end point was 90-day mortality; secondary adverse event end points included symptomatic intracranial hemorrhage and radiographic intracranial hemorrhage.

Results

The trial enrolled 300 patients (152 intervention, 148 control; 138 females [46%]; median age, 67 years), without early stopping or enrichment; 297 patients completed the 90-day follow-up. The mean (SD) 90-day UW-mRS score was 2.93 (3.39) for the intervention group vs 2.27 (2.98) for the control group with an adjusted difference of 0.63 (95% credible interval [CrI], -0.09 to 1.34; posterior probability for superiority of thrombectomy, .96). The 90-day mortality was similar between groups: 35.3% (53 of 150) for the intervention group vs 33.3% (49 of 147) for the control group. Six of 151 patients (4.0%) in the intervention group and 2 of 149 (1.3%) in the control group experienced 24-hour symptomatic intracranial hemorrhage. Fourteen patients of 148 (9.5%) in the intervention group vs 4 of 146 (2.7%) in the control group experienced parenchymal hematoma type 1 hemorrhages; 14 (9.5%) in the intervention group vs 5 (3.4%) in the control group experienced parenchymal hematoma type 2 hemorrhages; and 24 (16.2%) in the intervention group vs 9 (6.2%) in the control group experienced subarachnoid hemorrhages.

Conclusions and Relevance

Among patients with a large infarct on noncontrast CT within 24 hours, thrombectomy did not demonstrate improvement in functional outcomes. But the width of the credible interval around the effect estimate includes the possibility of both no important effect and a clinically relevant benefit, so the potential role of thrombectomy with this imaging approach and time window will likely require additional study.

Trial Registration

ClinicalTrials.gov Identifier: NCT03805308.

Adjunctive Intravenous Argatroban or Eptifibatide for Ischemic Stroke

BACKGROUND

Intravenous thrombolysis is a standard treatment of acute ischemic stroke. The efficacy and safety of combining intravenous thrombolysis with argatroban (an anticoagulant agent) or eptifibatide (an antiplatelet agent) are unclear.

METHODS

We conducted a phase 3, three-group, adaptive, single-blind, randomized, controlled clinical trial at 57 sites in the United States. Patients with acute ischemic stroke who had received intravenous thrombolysis within 3 hours after symptom onset were assigned to receive intravenous argatroban, eptifibatide, or placebo within 75 minutes after the initiation of thrombolysis. The primary efficacy outcome, the utility-weighted 90-day modified Rankin scale score (range, 0 to 10, with higher scores reflecting better outcomes), was assessed by means of centralized adjudication. The primary safety outcome was symptomatic intracranial hemorrhage within 36 hours after randomization.

RESULTS

A total of 514 patients were assigned to receive argatroban (59 patients), eptifibatide (227 patients), or placebo (228 patients). All the patients received intravenous thrombolysis (70% received alteplase, and 30% received tenecteplase), and 225 patients (44%) underwent endovascular thrombectomy. At 90 days, the mean (±SD) utility-weighted modified Rankin scale scores were 5.2±3.7 with argatroban, 6.3±3.2 with eptifibatide, and 6.8±3.0 with placebo. The posterior probability that argatroban was better than placebo was 0.002 (posterior mean difference in utility-weighted modified Rankin scale score, -1.51±0.51) and that eptifibatide was better than placebo was 0.041 (posterior mean difference, -0.50±0.29). The incidence of symptomatic intracranial hemorrhage was similar in the three groups (4% with argatroban, 3% with eptifibatide, and 2% with placebo). Mortality at 90 days was higher in the argatroban group (24%) and the eptifibatide group (12%) than in the placebo group (8%).

CONCLUSIONS

In patients with acute ischemic stroke treated with intravenous thrombolysis within 3 hours after symptom onset, adjunctive treatment with intravenous argatroban or eptifibatide did not reduce poststroke disability and was associated with increased mortality. (Funded by the National Institute of Neurological Disorders and Stroke; MOST ClinicalTrials.gov number, NCT03735979.).

Machine learning decision support model for discharge planning in stroke patients

BACKGROUND/AIM

Efficient discharge for stroke patients is crucial but challenging. The study aimed to develop early predictive models to explore which patient characteristics and variables significantly influence the discharge planning of patients, based on the data available within 24 h of admission.

DESIGN

Prospective observational study.

METHODS

A prospective cohort was conducted at a university hospital with 523 patients hospitalised for stroke. We built and trained six different machine learning (ML) models, followed by testing and tuning those models to find the best-suited predictor for discharge disposition, dichotomized into home and non-home. To evaluate the accuracy, reliability and interpretability of the best-performing models, we identified and analysed the features that had the greatest impact on the predictions.

RESULTS

In total, 523 patients met the inclusion criteria, with a mean age of 61 years. Of the patients with stroke, 30.01% had non-home discharge. Our model predicting non-home discharge achieved an area under the receiver operating characteristic curve of 0.95 and a precision of 0.776. After threshold was moved, the model had a recall of 0.809. Top 10 variables by importance were National Institutes of Health Stroke Scale (NIHSS) score, family income, Barthel index (BI) score, FRAIL score, fall risk, pressure injury risk, feeding method, depression, age and dysphagia.

CONCLUSION

The ML model identified higher NIHSS, BI, and FRAIL, family income, higher fall risk, pressure injury risk, older age, tube feeding, depression and dysphagia as the top 10 strongest risk predictors in identifying patients who required non-home discharge to higher levels of care. Modern ML techniques can support timely and appropriate clinical decision-making.

RELEVANCE TO CLINICAL PRACTICE

This study illustrates the characteristics and risk factors of non-home discharge in patients with stroke, potentially contributing to the improvement of the discharge process.

REPORTING METHOD

STROBE guidelines.

Using 30-day modified rankin scale score to predict 90-day score in patients with intracranial hemorrhage: Derivation and validation of prediction model

Whether 30-day modified Rankin Scale (mRS) scores can predict 90-day scores is unclear. This study derived and validated a model to predict ordinal 90-day mRS score in an intracerebral hemorrhage (ICH) population using 30-day mRS values and routinely available baseline variables. Adults enrolled in the Antihypertensive Treatment of Acute Cerebral Hemorrhage-2 (ATACH-2) trial between May 2011 and September 2015 with acute ICH, who were alive at 30 days and had mRS scores reported at both 30 and 90 days were included in this post-hoc analysis. A proportional odds regression model for predicting ordinal 90-day mRS scores was developed and internally validated using bootstrapping. Variables in the model included: mRS score at 30 days, age (years), hematoma volume (cm3), hematoma location (deep [basal ganglia, thalamus], lobar, or infratentorial), presence of intraventricular hemorrhage (IVH), baseline Glasgow Coma Scale (GCS) score, and National Institutes of Health Stroke Scale (NIHSS) score at randomization. We assessed model fit, calibration, discrimination, and agreement (ordinal, dichotomized functional independence), and EuroQol-5D ([EQ-5D] utility weighted) between predicted and observed 90-day mRS. A total of 898/1000 participants were included. Following bootstrap internal validation, our model (calibration slope = 0.967) had an optimism-corrected c-index of 0.884 (95% CI = 0.873-0.896) and R2 = 0.712 for 90-day mRS score. The weighted ĸ for agreement between observed and predicted ordinal 90-day mRS score was 0.811 (95% CI = 0.787-0.834). Agreement between observed and predicted functional independence (mRS score of 0-2) at 90 days was 74.3% (95% CI = 69.9-78.7%). The mean ± SD absolute difference between predicted and observed EQ-5D-weighted mRS score was negligible (0.005 ± 0.145). This tool allows practitioners and researchers to utilize clinically available information along with the mRS score 30 days after ICH to reliably predict the mRS score at 90 days.

Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage

BACKGROUND

Trials of surgical evacuation of supratentorial intracerebral hemorrhages have generally shown no functional benefit. Whether early minimally invasive surgical removal would result in better outcomes than medical management is not known.

METHODS

In this multicenter, randomized trial involving patients with an acute intracerebral hemorrhage, we assessed surgical removal of the hematoma as compared with medical management. Patients who had a lobar or anterior basal ganglia hemorrhage with a hematoma volume of 30 to 80 ml were assigned, in a 1:1 ratio, within 24 hours after the time that they were last known to be well, to minimally invasive surgical removal of the hematoma plus guideline-based medical management (surgery group) or to guideline-based medical management alone (control group). The primary efficacy end point was the mean score on the utility-weighted modified Rankin scale (range, 0 to 1, with higher scores indicating better outcomes, according to patients' assessment) at 180 days, with a prespecified threshold for posterior probability of superiority of 0.975 or higher. The trial included rules for adaptation of enrollment criteria on the basis of hemorrhage location. A primary safety end point was death within 30 days after enrollment.

RESULTS

A total of 300 patients were enrolled, of whom 30.7% had anterior basal ganglia hemorrhages and 69.3% had lobar hemorrhages. After 175 patients had been enrolled, an adaptation rule was triggered, and only persons with lobar hemorrhages were enrolled. The mean score on the utility-weighted modified Rankin scale at 180 days was 0.458 in the surgery group and 0.374 in the control group (difference, 0.084; 95% Bayesian credible interval, 0.005 to 0.163; posterior probability of superiority of surgery, 0.981). The mean between-group difference was 0.127 (95% Bayesian credible interval, 0.035 to 0.219) among patients with lobar hemorrhages and -0.013 (95% Bayesian credible interval, -0.147 to 0.116) among those with anterior basal ganglia hemorrhages. The percentage of patients who had died by 30 days was 9.3% in the surgery group and 18.0% in the control group. Five patients (3.3%) in the surgery group had postoperative rebleeding and neurologic deterioration.

CONCLUSIONS

Among patients in whom surgery could be performed within 24 hours after an acute intracerebral hemorrhage, minimally invasive hematoma evacuation resulted in better functional outcomes at 180 days than those with guideline-based medical management. The effect of surgery appeared to be attributable to intervention for lobar hemorrhages. (Funded by Nico; ENRICH ClinicalTrials.gov number, NCT02880878.).

Software with artificial intelligence-derived algorithms for analysing CT brain scans in people with a suspected acute stroke: a systematic review and cost-effectiveness analysis

Background

Artificial intelligence-derived software technologies have been developed that are intended to facilitate the review of computed tomography brain scans in patients with suspected stroke.

Objectives

To evaluate the clinical and cost-effectiveness of using artificial intelligence-derived software to support review of computed tomography brain scans in acute stroke in the National Health Service setting.

Methods

Twenty-five databases were searched to July 2021. The review process included measures to minimise error and bias. Results were summarised by research question, artificial intelligence-derived software technology and study type. The health economic analysis focused on the addition of artificial intelligence-derived software-assisted review of computed tomography angiography brain scans for guiding mechanical thrombectomy treatment decisions for people with an ischaemic stroke. The de novo model (developed in R Shiny, R Foundation for Statistical Computing, Vienna, Austria) consisted of a decision tree (short-term) and a state transition model (long-term) to calculate the mean expected costs and quality-adjusted life-years for people with ischaemic stroke and suspected large-vessel occlusion comparing artificial intelligence-derived software-assisted review to usual care.

Results

A total of 22 studies (30 publications) were included in the review; 18/22 studies concerned artificial intelligence-derived software for the interpretation of computed tomography angiography to detect large-vessel occlusion. No study evaluated an artificial intelligence-derived software technology used as specified in the inclusion criteria for this assessment. For artificial intelligence-derived software technology alone, sensitivity and specificity estimates for proximal anterior circulation large-vessel occlusion were 95.4% (95% confidence interval 92.7% to 97.1%) and 79.4% (95% confidence interval 75.8% to 82.6%) for Rapid (iSchemaView, Menlo Park, CA, USA) computed tomography angiography, 91.2% (95% confidence interval 77.0% to 97.0%) and 85.0 (95% confidence interval 64.0% to 94.8%) for Viz LVO (Viz.ai, Inc., San Fransisco, VA, USA) large-vessel occlusion, 83.8% (95% confidence interval 77.3% to 88.7%) and 95.7% (95% confidence interval 91.0% to 98.0%) for Brainomix (Brainomix Ltd, Oxford, UK) e-computed tomography angiography and 98.1% (95% confidence interval 94.5% to 99.3%) and 98.2% (95% confidence interval 95.5% to 99.3%) for Avicenna CINA (Avicenna AI, La Ciotat, France) large-vessel occlusion, based on one study each. These studies were not considered appropriate to inform cost-effectiveness modelling but formed the basis by which the accuracy of artificial intelligence plus human reader could be elicited by expert opinion. Probabilistic analyses based on the expert elicitation to inform the sensitivity of the diagnostic pathway indicated that the addition of artificial intelligence to detect large-vessel occlusion is potentially more effective (quality-adjusted life-year gain of 0.003), more costly (increased costs of £8.61) and cost-effective for willingness-to-pay thresholds of £3380 per quality-adjusted life-year and higher.

Limitations and conclusions

The available evidence is not suitable to determine the clinical effectiveness of using artificial intelligence-derived software to support the review of computed tomography brain scans in acute stroke. The economic analyses did not provide evidence to prefer the artificial intelligence-derived software strategy over current clinical practice. However, results indicated that if the addition of artificial intelligence-derived software-assisted review for guiding mechanical thrombectomy treatment decisions increased the sensitivity of the diagnostic pathway (i.e. reduced the proportion of undetected large-vessel occlusions), this may be considered cost-effective.

Future work

Large, preferably multicentre, studies are needed (for all artificial intelligence-derived software technologies) that evaluate these technologies as they would be implemented in clinical practice.

Study registration

This study is registered as PROSPERO CRD42021269609.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR133836) and is published in full in Health Technology Assessment; Vol. 28, No. 11. See the NIHR Funding and Awards website for further award information.

Serum uric acid and prognosis of ischemic stroke: Cohort study, meta-analysis and Mendelian randomization study

INTRODUCTION

The role of serum uric acid (UA) levels in the functional recovery of ischemic stroke remains uncertain. To evaluate whether UA could predict clinical outcomes in patients with ischemic stroke.

PATIENTS AND METHODS

A three-stage study design was employed, combining a large-scale prospective cohort study, a meta-analysis and a Mendelian randomization (MR) analysis. Firstly, we conducted a cohort study using data from the Nanjing Stroke Registry Program (NSRP) to assess the association between UA levels and 3-month functional outcomes in ischemic stroke patients. Secondly, the meta-analysis was conducted to integrate currently available cohort evidence. Lastly, MR analysis was utilized to explore whether genetically determined UA had a causal link to the functional outcomes of ischemic stroke using summary data from the CKDGen and GISCOME datasets.

RESULTS

In the first stage, the cohort study included 5631 patients and found no significant association between UA levels and functional outcomes at 3 months after ischemic stroke. In the second stage, the meta-analysis, including 10 studies with 14,657 patients, also showed no significant association between UA levels and stroke prognosis. Finally, in the third stage, MR analysis using data from 6165 patients in the GISCOME study revealed no evidence of a causal relationship between genetically determined UA and stroke functional outcomes.

DISCUSSION AND CONCLUSION

Our comprehensive triangulation approach found no significant association between UA levels and functional outcomes at 3 months after ischemic stroke.

Intravenous Thrombolysis in Posterior versus Anterior Circulation Stroke: Clinical Outcome Differs Only in Patients with Large Vessel Occlusion

The safety and efficacy of intravenous thrombolysis (IVT) are well established in anterior circulation stroke (ACS) but are much less clear for posterior circulation stroke (PCS). The aim of this study was to evaluate the occurrence of parenchymal hematoma (PH) and 3-month clinical outcomes after IVT in PCS and ACS. In an observational, cohort multicenter study, we analyzed data from ischemic stroke patients treated with IVT prospectively collected in the SITS (Safe Implementation of Treatments in Stroke) registry in the Czech Republic between 2004 and 2018. Out of 10,211 patients, 1166 (11.4%) had PCS, and 9045 (88.6%) ACS. PH was less frequent in PCS versus ACS patients: 3.6 vs. 5.9%, odds ratio (OR) = 0.594 in the whole set, 4.4 vs. 7.8%, OR = 0.543 in those with large vessel occlusion (LVO), and 2.2 vs. 4.7%, OR = 0.463 in those without LVO. At 3 months, PCS patients compared with ACS patients achieved more frequently excellent clinical outcomes (modified Rankin scale [mRS] 0-1: 55.5 vs. 47.6%, OR = 1.371 in the whole set and 49.2 vs. 37.6%, OR = 1.307 in those with LVO), good clinical outcomes (mRS 0-2: 69.9 vs. 62.8%, OR = 1.377 in the whole set and 64.5 vs. 50.5%, OR = 1.279 in those with LVO), and had lower mortality (12.4 vs. 16.6%, OR = 0.716 in the whole set and 18.4 vs. 25.5%, OR = 0.723 in those with LVO) (p < 0.05 in all cases). In PCS versus ACS patients, an extensive analysis showed a lower risk of PH both in patients with and without LVO, more frequent excellent and good clinical outcomes, and lower mortality 3 months after IVT in patients with LVO.

Trends of Sex Differences and Associated Factors in Stroke Outcomes Among Patients With Acute Ischemic Stroke: 2007 to 2018

BACKGROUND AND OBJECTIVES

Female patients have been shown to experience worse clinical outcomes after acute ischemic stroke (AIS) compared with male patients. We aimed to estimate the temporal trends in the sex differences in stroke outcomes and identify risk factors contributing to the sex differences spanning 10 years in China.

METHODS

This cohort study was conducted based on data from the China National Stroke Registries (CNSRs, comprising 3 phases, I-III, from 2007 to 2018). Patients with ischemic stroke within 7 days of symptom onset were included. The primary outcome was a 12-month poor functional outcome. Other outcomes included mortality and disability-adjusted life-year (DALY) lost. The sex differences in outcomes and associated factors were estimated using multivariable logistic regression. The sex differences between CNSRs were tested by the interaction of sex and time.

RESULTS

Among 42,564 patients included, 35.4% were female. The age-adjusted event rate of 12-month poor functional outcome and mortality decreased both in male and female patients after stroke onset (CNSRs I, II, and III, all p varies over time <0.001). There was a decrease in DALY lost for both sexes over the decade (male patients: from 10.1 to 9.3 DALYs; female patients: from 10.9 to 9.6 DALYs). Female patients showed worse 12-month poor functional outcome in CNSRs I and II (odds ratio [OR] with 95% CI: 1.24 [1.10-1.39] and 1.12 [1.01-1.25], respectively) compared with male patients, but the sex difference attenuated in CNSR III (OR with 95% CI: 1.02 [0.89-1.16]), with the temporal trend (p varies over time = 0.004). The sex difference and the temporal trend of the sex difference in mortality from 2007 to 2018 were not found (p varies over time = 0.45). The most important factors attenuating the sex difference in poor functional outcome in CNSRs I and III were education level, socioeconomic deprivation, baseline stroke severity, and current smoking.

DISCUSSION

This study demonstrated that the sex disparity in poor functional outcome at 12 months was substantially narrowed covering 10 years and completely attenuated in 2015-2018. The findings suggested that female patients have experienced larger improvements in stroke outcomes than male patients over the past decade.

Comparative study on clinical outcomes and cost-effectiveness of chronic subdural hematomas treated by middle meningeal artery embolization and conventional treatment: a national cross-sectional study

BACKGROUND

The authors compared the efficacy and cost-effectiveness of middle meningeal artery embolization (MMAE) and conventional treatment for chronic subdural hematomas (cSDH).

METHODS

The Nationwide Readmissions Database of 9963 patients (27.2% women) with cSDH between 2016 and 2020 was analyzed. Finally, 9532 patients were included (95.7%, treated conventionally; 4.3%, treated with MMAE). Baseline demographics, comorbidities, adverse events, treatment strategies, and outcomes were compared between patients treated with MMAE and conventional treatment. After propensity score matching, the authors compared primary outcomes, including the 90-day treatment rate, functional outcome, length of hospital stays, and cost. A Markov model estimated lifetime costs and quality-adjusted life years (QALYs) associated with different treatments. The incremental cost-effectiveness ratio (ICER) was calculated to evaluate the base-case scenario. One-way, two-way, and probabilistic sensitivity analyses were performed to evaluate the uncertainty in the results.

RESULTS

After propensity score matching, MMAE had a lower 90-day retreatment rate (2.6 vs. 9.0%, P =0.001), shorter length of hospital stays (4.61±6.19 vs. 5.73±5.76 days, P =0.037), similar functional outcomes compared (favorable outcomes, 80.9 vs. 74.8%, P =0.224) but higher costs ($119 757.71±90 378.70 vs. $75 745.55±100 701.28, P <0.001) with conventional treatment. MMAE was associated with an additional cost of US$19 280.0 with additional QALY of 1.3. Its ICER was US$15199.8/QALY.

CONCLUSION

MMAE is more effective in treating cSDH than conventional treatment. Based on real-world data, though MMAE incurs higher overall costs, the Markov model showed it to be cost-effective compared to conventional treatment under the American healthcare system. These comparative and economic analyses further support the consideration of a paradigm shift in cSDH treatment.

Co-designing an interactive artificial intelligent system with post-stroke patients and caregivers to augment the lost abilities and improve their quality of life: a human-centric approach

Objectives

The motor disability due to stroke compromises the autonomy of patients and caregivers. To support autonomy and other personal and social needs, trustworthy, multifunctional, adaptive, and interactive assistive devices represent optimal solutions. To fulfill this aim, an artificial intelligence system named MAIA would aim to interpret users' intentions and translate them into actions performed by assistive devices. Analyzing their perspectives is essential to develop the MAIA system operating in harmony with patients' and caregivers' needs as much as possible.

Methods

Post-stroke patients and caregivers were interviewed to explore the impact of motor disability on their lives, previous experiences with assistive technologies, opinions, and attitudes about MAIA and their needs. Interview transcripts were analyzed using inductive thematic analysis.

Results

Sixteen interviews were conducted with 12 post-stroke patients and four caregivers. Three themes emerged: (1) Needs to be satisfied, (2) MAIA technology acceptance, and (3) Perceived trustfulness. Overall, patients are seeking rehabilitative technology, contrary to caregivers needing assistive technology to help them daily. An easy-to-use and ergonomic technology is preferable. However, a few participants trust a system based on artificial intelligence.

Conclusion

An interactive artificial intelligence technology could help post-stroke patients and their caregivers to restore motor autonomy. The insights from participants to develop the system depends on their motor ability and the role of patients or caregiver. Although technology grows exponentially, more efforts are needed to strengthen people's trust in advanced technology.

Staged use of ordinal and linear disability scales: a practical approach to granular assessment of acute stroke outcome

Background

The modified Rankin Scale (mRS) assessment of global disability is the most common primary endpoint in acute stroke trials but lacks granularity (7 broad levels) and is ordinal (scale levels unknown distances apart), which constrains study power. Disability scales that are linear and continuous may better discriminate outcomes, but computerized administration in stroke patients is challenging. We, therefore, undertook to develop a staged use of an ordinal followed by a linear scale practical to use in multicenter trials.

Methods

Consecutive patients undergoing 3-month final visits in the NIH FAST-MAG phase 3 trial were assessed with the mRS followed by 15 mRS level-specific yes-no items of the Academic Medical Center Linear Disability Score (ALDS), a linear disability scale derived using item response theory.

Results

Among 55 patients, aged 71.2 (SD ± 14.2), 67% were men and the entry NIHSS was 10.7 (SD ± 9.5). At 90 days, the median mRS score was 3 (IQR, 1-4), and the median ALDS score was 78.8 (IQR, 3.3-100). ALDS scores correlated strongly with 90 days outcome measures, including the Barthel Index (r = 0.92), NIHSS (r = 0.87), and mRS (r = 0.94). ALDS scores also correlated modestly with entry NIHSS (r = 0.38). At 90 days, the ALDS showed greater scale granularity than the mRS, with fewer patients with identical values, 1.9 (SD ± 3.2) vs. 8.0 (SD ± 3.6), p < 0.001. When treatment effect magnitudes were small to moderate, projected trial sample size requirements were 2-12-fold lower when the ALDS rather than the mRS was used as the primary trial endpoint.

Conclusion

Among patients enrolled in an acute neuroprotective stroke trial, the ALDS showed strong convergent validity and superior discrimination characteristics compared with the modified Rankin Scale and increased projected trial power to detect clinically meaningful treatment benefits.

Vertebrobasilar artery cooling infusion in acute ischemic stroke for posterior circulation following thrombectomy: Rationale, design and protocol for a prospective randomized controlled trial

BACKGROUND

Although endovascular mechanical thrombectomy demonstrates clinical efficacy in posterior circulation acute ischemic stroke (AIS), only one third of these patients attain functional independence with a third of patients' expiring despite vascular recanalization. Neuroprotection strategies, such as therapeutic hypothermia (TH) have been considered a promising adjunctive treatment in AIS. We propose the following rationale, design and protocol for a prospective randomized controlled trial (RCT) aimed to determine whether Vertebrobasilar Artery Cooling Infusion (VACI) improves functional outcomes in posterior circulation AIS patients post mechanical thrombectomy.

METHODS

Subjects in the study will be assigned randomly to either the cooling infusion or the control group in a 1:1 ratio (n = 40). Patients allocated to the cooling infusion group will receive 300 ml cool saline at 4C through the catheter (30 ml/min) into vertebral artery after thrombectomy. The control group will receive the same volume of 37C saline. All patients enrolled will receive standard care according to current guidelines for stroke management. The primary outcome is symptomatic intracranial hemorrhage (ICH), whereas the secondary outcomes include functional outcome score, infarction volume, mortality, ICH, fatal ICH, cerebral vasospasm, coagulation abnormality, pneumonia and urinary infection.

DISCUSSIONS

This study will determine the preliminary safety, feasibility, and neuroprotective benefits of VACI in posterior circulation AIS patients with reperfusion therapy. The results of this study may provide evidence for VACI as a new therapy in posterior circulation AIS.

CLINICAL TRIAL REGISTRATION

www.chictr.org.cn, ChiCTR2200065806, registered on November 15, 2022.

Real-World Populational-Based Quality of Life and Functional Status After Stroke

OBJECTIVES

This study aimed to describe health-related quality of life (HRQoL) 3 months and 1 year after stroke, compare HRQoL between dependent (modified Rankin scale [mRS] 3-5) and independent (mRS 0-2) patients, and identify factors predictive of poor HRQoL.

METHODS

Patients with a first ischemic stroke or intraparenchymal hemorrhage from the Joinville Stroke Registry were analyzed retrospectively. Using the 5-level version of the EuroQol-5D questionnaire, HRQoL was calculated for all patients 3 months and 1 year after stroke, stratified by mRS score (0-2 or 3-5). One-year HRQoL predictors were examined using univariate and multivariate analyses.

RESULTS

Three months after a stroke, data from 884 patients were analyzed; 72.8% were categorized as mRS 0-2 and 27.2% as mRS 3-5, and the mean HRQoL was 0.670 ± 0.256. At 1-year follow-up, 705 patients were evaluated; 75% were classified as mRS 0-2 and 25% as mRS 3-5, and the mean HRQoL was 0.71 ± 0.249. An increase in HRQoL was observed between 3 months and 1 year (mean difference 0.024, P < .0001), both in patients with 3-month mRS 0-2 (0.013, P = .027) and mRS 3-5 (0.052, P < .0001). Increasing age, female sex, hypertension, diabetes, and a high mRS were associated with poor HRQoL at 1 year.

CONCLUSIONS

This study described the HRQoL after a stroke in a Brazilian population. This analysis shows that the mRS was highly associated with HRQoL after stroke. Age, sex, diabetes, and hypertension were also associated with HRQoL, although not independently of mRS.

Some home-based self-managed rehabilitation interventions can improve arm activity after stroke: A systematic review and narrative synthesis

Background

There is an increased need for home-based, self-managed, and low maintenance stroke rehabilitation as well as interest in targeting the arm, which often lags behind leg recovery. Previous reviews have not controlled for concurrent standard of care and the ratio of self-managed care to therapist input.

Objectives

To determine the effectiveness of home-based, self-managed and low maintenance programs for upper-limb motor recovery in individuals after stroke. A secondary objective explored the adherence to home-based self-managed programs.

Data sources

We searched PubMed (1809-present), Embase (embase.com, 1974-present), Cochrane CENTRAL Register of Controlled Trials (Wiley), CINAHL (EBSCOhost, 1937-present), Physiotherapy Evidence Database (pedro.org.au), OTseeker (otseeker.com), and REHABDATA (National Rehabilitation Information Center). All searches were completed on June 9, 2022. Bibliographic references of included articles also were searched.

Eligibility criteria

Randomized controlled trials (RCT) in adults after stroke, where both intervention and control were home-based, at least 75% self-managed and did not involve concurrent therapy as a confounding factor. Primary outcome was performance in functional motor activities after training. Secondary outcome was sensorimotor impairment. All outcomes after a retention period were also considered secondary outcomes.

Data collection and analysis

Two review authors independently screened titles/abstracts, three review authors screened full papers and extracted data, and two review authors undertook assessment of risk of bias (i.e., allocation bias, measurement bias, confounding factors) using the NHLBI Study Quality Assessment Tool.

Main results

We identified seven heterogenous studies, including five with fair to good quality. All studies had an alternative treatment, dose-equivalent control. Only one trial reported a positive, sustained, between-group effect on activity for the experimental group. The remaining studies reported seven interventions having a within-group training effect with three interventions having sustained effects at follow up. One study reported a between group effect on an impairment measure with no follow-up. Overall adherence rates were high, but three studies reported differential group rates. Compliance with daily logs was higher when the logs were collected on a weekly basis.

Limitations

By excluding studies that allowed concurrent therapy, we likely minimized the number of studies that included participants in the early sub-acute post-stroke stage. By focusing on RCTs, we are unable to comment on other potentially promising home-based, self-managed single cohort programs. By including only published and English language studies, we may have included publication bias.

Conclusions and implications

There is some evidence that a variety of home-based, self-managed training program can be beneficial after stroke. Future research could compare such programs with natural history controls. Clinicians might utilize home exercise programs with explicit directions and some form of weekly contact to aid compliance.

Long-term functional independence after minimally invasive endoscopic intracerebral hemorrhage evacuation

OBJECTIVE

Intracerebral hemorrhage (ICH) is a devastating form of stroke with no proven treatment. However, minimally invasive endoscopic evacuation is a promising potential therapeutic option for ICH. Herein, the authors examine factors associated with long-term functional independence (modified Rankin Scale [mRS] score ≤ 2) in patients with spontaneous ICH who underwent minimally invasive endoscopic evacuation.

METHODS

Patients with spontaneous supratentorial ICH who had presented to a large urban healthcare system from December 2015 to October 2018 were triaged to a central hospital for minimally invasive endoscopic evacuation. Inclusion criteria for this study included age ≥ 18 years, hematoma volume ≥ 15 ml, National Institutes of Health Stroke Scale (NIHSS) score ≥ 6, premorbid mRS score ≤ 3, and time from ictus ≤ 72 hours. Demographic, clinical, and radiographic factors previously shown to impact functional outcome in ICH were included in a retrospective univariate analysis with patients dichotomized into independent (mRS score ≤ 2) and dependent (mRS score ≥ 3) outcome groups, according to 6-month mRS scores. Factors that reached a threshold of p < 0.05 in a univariate analysis were included in a multivariate logistic regression.

RESULTS

A total of 90 patients met the study inclusion criteria. The median preoperative hematoma volume was 41 (IQR 27-65) ml and the median postoperative volume was 1.2 (0.3-7.5) ml, resulting in a median evacuation percentage of 97% (85%-99%). The median hospital length of stay was 17 (IQR 9-25) days, and 8 (9%) patients died within 30 days of surgery. Twenty-four (27%) patients had attained functional independence by 6 months. Factors independently associated with long-term functional independence included lower NIHSS score at presentation (OR per point 0.78, 95% CI 0.67-0.91, p = 0.002), lack of intraventricular hemorrhage (IVH; OR 0.20, 95% CI 0.05-0.77, p = 0.02), and shorter time to evacuation (OR per hour 0.95, 95% CI 0.91-0.99, p = 0.007). Specifically, patients who had undergone evacuation within 24 hours of ictus demonstrated an mRS score ≤ 2 rate of 36% and were associated with an increased likelihood of long-term independence (OR 17.7, 95% CI 1.90-164, p = 0.01) as compared to those who had undergone evacuation after 48 hours.

CONCLUSIONS

In a single-center minimally invasive endoscopic ICH evacuation cohort, NIHSS score on presentation, lack of IVH, and shorter time to evacuation were independently associated with functional independence at 6 months. Factors associated with functional independence may help to better predict populations suitable for minimally invasive endoscopic evacuation and guide protocols for future clinical trials.

Mechanical thrombectomy is cost-effective versus medical management alone around Europe in patients with low ASPECTS

OBJECTIVE

To demonstrate, by a cost-effectiveness analysis, the efficiency of mechanical thrombectomy (MT) versus medical management (MM) in patients with a low Alberta Stroke Program Early CT Score (ASPECTS) from the RESCUE Study.

METHODS

A cost-effectiveness model was designed to project both direct medical costs and quality-adjusted life-years (QALYs) of MT versus MM in eight European countries (Spain, UK, France, Italy, Belgium, Germany, Sweden, and the Netherlands). Our model was created based on previously published health-economic data in those countries. Procedure costs, acute, mid-term, and long-term care costs were projected based on expected modified Rankin Scale (mRS) scores as reported in the RESCUE-Japan LIMIT trial.

RESULTS

MT was found to be a cost-effective option in eight different countries across Europe (Spain, Italy, UK, France, Belgium, Germany, the Netherlands, and Sweden). with a lifetime incremental cost-effectiveness ratio varying from US$2 875 to US$11 202/QALY depending on the country. A cost-effectiveness acceptability curve showed 100% acceptability of MT at the willingness to pay (WTP) of US$40 000 for the eight countries.

CONCLUSIONS

MT is efficient versus MM alone for patients with low ASPECTS in eight countries across Europe. Patients with a large ischemic core could be treated with MT because it is both clinically beneficial and economically sustainable.

Parametric and nonparametric methods for confidence intervals and sample size planning for win probability in parallel‐group randomized trials with Likert item and Likert scale data

Data on the Likert scale are ubiquitous in medical research, including randomized trials. Statistical analysis of such data may be conducted using the means of raw scores or the rank information of the scores. In the context of parallel-group randomized trials, we quantify treatment effects by the probability that a subject in the treatment group has a better score than (or a win over) a subject in the control group. Asymptotic parametric and nonparametric confidence intervals for this win probability and associated sample size formulas are derived for studies with only follow-up scores, and those with both baseline and follow-up measurements. We assessed the performance of both the parametric and nonparametric approaches using simulation studies based on real studies with Likert item and Likert scale data. The simulation results demonstrate that even without baseline adjustment, the parametric methods did not perform well, in terms of bias, interval coverage percentage, balance of tail error, and assurance of achieving a pre-specified precision. In contrast, the nonparametric approach performed very well for both the unadjusted and adjusted win probability. We illustrate the methods with two examples: one using Likert item data and the other using Like scale data. We conclude that non-parametric methods are preferable for two-group randomization trials with Likert data. Illustrative SAS code for the nonparametric approach using existing procedures is provided.

[Psychometric properties of the Post-COVID 19 Functional Status scale for adult COVID 19 survivors]

INTRODUCTION

To evaluate functional state, it is fundamental to have simple instruments that allow for monitoring the course of symptoms and the commitment of the functional status that adult COVID-19 survivors may present. This study aims to evaluate the psychometric properties of the Post COVID-19 Functional Status (PCFS) scale.

MATERIAL AND METHODS

A cross-sectional scale validation study was performed. In the content validation 22-health professionals, whom through expert judgment evaluated the scale in the sufficiency, clarity, coherence and relevance categories. In addition, two professionals performed the retest with 20 people who had been infected with COVID-19. In addition, their observations and comments are revealed. The degree of agreement amongst the experts was determined with the Kendall coefficient. For the retest test, the Spearman coefficient was utilized. In all the analyzes, a P value of <.05 was considered.

RESULTS

In regards to the content validity, there was agreement between raters only for the relevance category (P=.032). A strong agreement was obtained between two evaluators (Spearman's Rho=.929 for the score). Some of the content terms were adjusted without affecting the general structure of the scale. Of the original 16 items that make up the PCFS scale, none was eliminated.

CONCLUSIONS

The Spanish version of the PCFS (Chile) was adapted to the cultural context of the country, shows good psychometric characteristics in terms of reliability.

Distribution-Free Approach to the Design and Analysis of Randomized Stroke Trials With the Modified Rankin Scale

BACKGROUND

Many methods have been suggested for analyzing the modified Rankin Scale (mRS). However, there lacks a unified approach to analysis and sample size determination that properly uses the ordinal nature of the data. We propose a simple method for CI estimation and corresponding sample size determination.

METHODS

We quantify treatment effect by the win probability (WinP) that a randomly selected patient in the treatment group has an equal or a better mRS score than a patient in the control group. Thus, a win probability of 0.5 means no effect, likened to a draw in competitive sports. We estimate the win probability and its SE based on the ranks of mRS scores, where tied scores are handled by average ranks. Corresponding methods for hypothesis testing, CI estimation, and sample size determination are derived. The methods are evaluated with a simulation study based on real data from 10 randomized stroke trials that used mRS as the outcome measure.

RESULTS

Simulation results demonstrated that the methods performed very well in terms of CI coverage, tail errors, and assurance to achieving the prespecified precision. Because the methods are very simple, we implemented them in an Excel spreadsheet, requiring only user inputs on frequencies of mRS scores in 2 comparison groups.

CONCLUSIONS

Sound statistical methods are important for the success of randomized stroke trials. The proposed methods and associated spreadsheet should prove useful for stroke researchers in the planning and analysis of randomized trials. Meta-analysis has also been made easy for trials with ordinal scores.

Association of Pre-stroke Frailty With Prognosis of Elderly Patients With Acute Cerebral Infarction: A Cohort Study

Background

Frailty is a state of cumulative degradation of physiological functions that leads to adverse outcomes such as disability or mortality. Currently, there is still little understanding of the prognosis of pre-stroke frailty status with acute cerebral infarction in the elderly.

Objective

We investigated the association between pre-stroke frailty status, 28-day and 1-year survival outcomes, and functional recovery after acute cerebral infarction.

Methods

Clinical data were collected from 314 patients with acute cerebral infarction aged 65–99 years. A total of 261 patients completed follow-up in the survival cohort analysis and 215 patients in the functional recovery cohort analysis. Pre-stroke frailty status was assessed using the FRAIL score, the prognosis was assessed using the modified Rankin Scale (mRS), and disease severity using the National Institutes of Health Stroke Scale (NIHSS).

Results

Frailty was independently associated with 28-day mortality in the survival analysis cohort [hazard ratio (HR) = 4.30, 95% CI 1.35–13.67, p = 0.014]. However, frailty had no independent effect on 1-year mortality (HR = 1.47, 95% CI 0.78–2.79, p = 0.237), but it was independently associated with advanced age, the severity of cerebral infarction, and combined infection during hospitalization. Logistic regression analysis after adjusting for potential confounders in the functional recovery cohort revealed frailty, and the NIHSS score was significantly associated with post-stroke severe disability (mRS > 2) at 28 days [pre-frailty adjusted odds ratio (aOR): 8.86, 95% CI 3.07–25.58, p < 0.001; frailty aOR: 7.68, 95% CI 2.03–29.12, p = 0.002] or 1 year (pre-frailty aOR: 8.86, 95% CI 3.07–25.58, p < 0.001; frailty aOR: 7.68, 95% CI 2.03–29.12, p = 0.003).

Conclusions

Pre-stroke frailty is an independent risk factor for 28-day mortality and 28-day or 1-year severe disability. Age, the NIHSS score, and co-infection are likewise independent risk factors for 1-year mortality.

A systematic literature review of disability weights measurement studies: evolution of methodological choices

Background

The disability weight is an essential factor to estimate the healthy time that is lost due to living with a certain state of illness. A 2014 review showed a considerable variation in methods used to derive disability weights. Since then, several sets of disability weights have been developed. This systematic review aimed to provide an updated and comparative overview of the methodological design choices and surveying techniques that have been used in disability weights measurement studies and how they evolved over time.

Methods

A literature search was conducted in multiple international databases (early-1990 to mid-2021). Records were screened according to pre-defined eligibility criteria. The quality of the included disability weights measurement studies was assessed using the Checklist for Reporting Valuation Studies (CREATE) instrument. Studies were collated by characteristics and methodological design approaches. Data extraction was performed by one reviewer and discussed with a second.

Results

Forty-six unique disability weights measurement studies met our eligibility criteria. More than half (n = 27; 59%) of the identified studies assessed disability weights for multiple ill-health outcomes. Thirty studies (65%) described the health states using disease-specific descriptions or a combination of a disease-specific descriptions and generic-preference instruments. The percentage of studies obtaining health preferences from a population-based panel increased from 14% (2004–2011) to 32% (2012–2021). None of the disability weight studies published in the past 10 years used the annual profile approach. Most studies performed panel-meetings to obtain disability weights data.

Conclusions

Our review reveals that a methodological uniformity between national and GBD disability weights studies increased, especially from 2010 onwards. Over years, more studies used disease-specific health state descriptions in line with those of the GBD study, panel from general populations, and data from web-based surveys and/or household surveys. There is, however, a wide variation in valuation techniques that were used to derive disability weights at national-level and that persisted over time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00860-z.

Association of Modified Rankin Scale With Recovery Phenotypes in Patients With Upper Extremity Weakness After Stroke

BACKGROUND

Precise measurement of outcomes is essential for stroke trials and clinical care. Prior research has highlighted conceptual differences between global outcome measures such as the Modified Rankin Scale (mRS) and domain-specific measures (e.g. motor, sensory, language or cognitive function). This study related motor phenotypes to the mRS, specifically aiming to (1) determine whether mRS levels distinguish motor impairment and function phenotypes, and (2) compare mRS outcomes to meaningful changes in impairment and function from acute to subacute recovery after stroke.

METHODS

Patients with upper extremity weakness after ischemic stroke were assessed with a battery of impairment and functional measures within the first week and at 90-days post-stroke. Impairment and functional outcomes were examined in relation to 90-day mRS scores. Clinically meaningful changes in motor impairment, activities of daily living, and mobility were examined in relation to 90-day mRS.

RESULTS

In this cohort of n = 73 stroke patients, impairment and functional outcomes were associated with 90-day mRS scores but showed substantial variability within individual mRS levels: within mRS level 2, upper extremity impairment ranged from near hemiplegia (with an upper extremity Fugl-Meyer 8) to no deficits (upper extremity Fugl-Meyer 66). Overall, there were few differences in impairment and functional outcomes between adjacent mRS levels. While some outcome measures were significantly different between mRS levels 3 and 4 (Nine-Hole Peg, Leg Motor, Gait Velocity, Timed Up and Go, National Institutes of Health Stroke Scale, and Barthel Index), none of the outcome measures differed between mRS levels 1 and 2. Fugl-Meyer and Grip Strength were not different between any adjacent mRS levels. A substantial number of patients experienced clinically meaningful changes in impairment and function in the first 90 days post-stroke but did not achieve good mRS outcome (mRS ≤ 2).

CONCLUSIONS

The mRS broadly relates to domain-specific outcomes after stroke confirming its established value in stroke trials, but it does not precisely distinguish differences in impairment and function nor does it sufficiently capture meaningful clinical changes across impairment, ADL status, and mobility. These findings underscore the potential utility of incorporating detailed phenotypic measures alongside the mRS in future stroke trials.

Seeing the good in the bad: actual clinical outcome of thrombectomy stroke patients with formally unfavorable outcome

Purpose

Clinical outcome of stroke patients is usually classified into favorable (modified Rankin scale (mRS) 0–2) and unfavorable (mRS 3–5) outcome according to the modified Rankin scale. We took a closer look at the clinical course of thrombectomy stroke patients with formal unfavorable outcome and assessed whether we could achieve our treatment goals and/or neurological improvement in these patients.

Methods

We studied 107 patients with occlusions in the terminal carotid artery or the M1 segment of the middle cerebral artery, in whom complete recanalization (eTICI 3) could be achieved, and who had an mRS of 3–5 at 90 days. We analyzed whether an individual treatment goal (i.e., preventing aphasia) and neurological improvement (NIHSS) could be achieved. In addition, we examined whether there was clinical improvement on the mRS.

Results

The treatment goal was achieved in 52% (53/103) and neurological improvement in 65% (67/103). mRS 90 days post-stroke was better than mRS upon admission in 36% (38/107) and better than or equal to mRS upon admission in 80% (86/107). Of the 93 patients with known pre-stroke mRS, 18% (17/93) already had an mRS ≥ 3, with 15 of these 17 patients having a worse mRS on admission than before. Of these 17 patients, 18% regained baseline, and 24% improved from admission.

Conclusion

Dichotomizing the mRS into favorable and unfavorable outcome does not do justice to the full spectrum of stroke. Patients with formal unfavorable outcome after mRS can improve neurologically, achieve treatment goals, and even regain their admission or pre-stroke mRS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00234-022-02920-1.

Effect of Vitamin D Supplementation on the Prognosis of Post-stroke Fatigue: A Retrospective Cohort Study

Objective: We aimed to evaluate the effect of vitamin D supplementation in post-stroke fatigue (PSF) patients with vitamin D deficiency on fatigue symptoms and outcomes. Methods: Patients with primary acute ischemic stroke (AIS) were recruited consecutively from July 2016 to June 2018. Post-stroke fatigue patients were screened out with the Fatigue Severity Scale (FSS) questionnaire, serum concentrations of 25-hydroxyvitamin D [25-(OH)-D] were assessed with enzyme-linked immunosorbent assay (ELISA), and neurological function was evaluated with FSS and modified Rankin Scale (mRS) scoring criteria. Post-stroke fatigue patients with vitamin D deficiency were divided into two groups: a study group in which patients received vitamin D supplementation (cholecalciferol, 600 IU/day) along with usual care, and a control group in which patients received usual care alone. At the end of 1 and 3 months after treatment, all PSE patients accepted re-measurement of serum vitamin D and re-evaluation of fatigue and neurological function. Results: A total of 532 AIS patients were consecutively recruited to participate in this study. Patients without PSF, non-vitamin D deficiency, pre-stroke fatigue, or vitamin D supplementation were excluded from the study. In addition, patients who were lost to follow-up were also excluded. Finally, 139 out of 532 (26.1%) patients with PSF and vitamin D deficiency received vitamin D supplementation treatment. Fatigue Severity Scale score was significantly lower in the study group than in the control group at 1 month (t = -4.731, p < 0.01) and 3 months (t = -7.937, p < 0.01) after treatment. One month after treatment, mRS score in the study group was lower than that in the control group without statistical difference (t = -0.660, p > 0.05), whereas mRS was significantly higher in the study group than in the control group at 3 months after treatment (t = -4.715, p < 0.01). Conclusions: Our results indicated that vitamin D supplementation could improve fatigue symptoms and neurological outcomes in PSF patients with vitamin D deficiency. Subject to replication in other settings, a randomized controlled trial (RCT) might be undertaken to validate the potential beneficial impact of vitamin D supplementation in post-stroke patients found to be vitamin D deficient.

Stroke Center Designations, Neurointerventionalist Demand, and the Finances of Stroke Thrombectomy in the United States

PURPOSE OF THE REVIEW

This article aims to provide an update on the designation of stroke centers, neurointerventionalist demand, and cost-effectiveness of stroke thrombectomy in the United States.

RECENT FINDINGS

There are now more than 1,660 stroke centers certified by national accrediting bodies in the United States, 306 of which are designated as thrombectomy-capable or comprehensive stroke centers. Considering the amount of nationally certified centers and the number of patients with acute stroke eligible for thrombectomy, each center would be responsible for 64 to 104 thrombectomies per year. As a result, there is a growing demand placed on neurointerventionalists, who have the ability to alter the trajectory of large vessel occlusive strokes. Numbers needed to achieve functional independence after stroke thrombectomy at 90 days range from 3.2 to 7.4 patients in the early time window and 2.8 to 3.6 patients in the extended time window in appropriately selected candidates. With the low number needed to treat, in a variety of valued-based calculations and cost-effectiveness analyses, stroke thrombectomy has proved to be both clinically effective and cost-effective.

SUMMARY

Advancements in the early recognition and treatment of stroke have been paralleled by a remodeling of health care systems to ensure best practices in a timely manner. Stroke center-accrediting bodies provide oversight to safeguard these standards. As successful trial data from high volume centers transform into real-world experience, we must continue to re-evaluate cost-effectiveness, strike a balance between sufficient case volumes to maintain clinical excellence vs the burden and burnout associated with call responsibilities, and improve access to care for all.

Association between aspirin-induced hemoglobin decline and outcome after acute ischemic stroke in G6PD-deficient patients

Aims

The risk of hemoglobin decline induced by low‐dose aspirin in glucose‐6‐phosphate dehydrogenase (G6PD) deficiency remains unknown, and its influence on stroke outcome remains to be investigated. This study aimed to evaluate the effect of G6PD deficiency on hemoglobin level during aspirin treatment and its association with outcome after acute ischemic stroke.

Methods

In total, 279 patients (40 G6PD‐deficient and 239 G6PD‐normal) with acute ischemic stroke treated with aspirin 100 mg/day from a cohort study were examined. The primary safety endpoint was a hemoglobin decline ≥25 g/L or 25% from baseline within 14 days after aspirin treatment. Poor outcomes were defined as a modified Rankin Scale score ≥2 at 3 months. The χ² test was used to compare stroke outcomes, and multivariate logistic regression analyses were performed to analyze the association between hemoglobin level and outcomes.

Results

The G6PD‐deficient group had lower baseline hemoglobin and tended to develop comorbid pulmonary infection more frequently (p < 0.05). The proportion of patients with hemoglobin decline ≥25 g/L or 25% from baseline (15.0% vs. 3.3%; p = 0.006) and anemia (30.0% vs. 14.6%; p = 0.016) after aspirin treatment was higher in the G6PD‐deficient group, which was accompanied by a more significant bilirubin increase. The rate of poor functional outcomes at 3 months after acute ischemic stroke was higher in the G6PD‐deficient group (Risk ratio = 1.31 [95% confidence interval (CI) = 1.10–1.56]; p = 0.017). Confounder‐adjusted analysis showed that lower hemoglobin levels (odds ratio = 0.98 [95% CI = 0.96–0.99]; adjusted p = 0.009) increased the risk of poor functional outcomes.

Conclusion

Hemoglobin decrease with bilirubin increase after aspirin treatment in patients with G6PD deficiency suggests hemolysis, which may influence stroke prognosis. The risk of hemoglobin decline should be carefully monitored in G6PD‐deficient patients with ischemic stroke taking aspirin.

Very early mobilization in the stroke unit: Functionality, quality of life and disability at 90 days and 1 year post-stroke

BACKGROUND

The evidence of early mobilization after stroke is conflicting, and the recovery period is an important concern.

OBJECTIVE

To analyse the functionality, quality of life and disability at 90 days and 1 year post-stroke of patients who received a Very Early Mobilization Protocol (VEMP).

METHODS

Prospective cohort study in a tertiary stroke unit. Consecutive patients aged≥18 years and without prior significant disability, who presented motor deficit after acute stroke, were included. A symmetry test was performed to compare the changes in the main variables: Barthel Index (BI), Functional Ambulation Category (FAC), modified Rankin Scale (mRS) and EuroQol five-dimensions three-level (EQ-5D-3L) between 90 days and 1 year post-stroke.

RESULTS

A total of 123 patients were recruited. The BI reflected an improvement at 1 year in transfer to chair/bed in 25.8%(p <  0.01) of patients and in toilet use in 25.8%(p = 0.02). The FAC showed an improvement at 1 year in 44.4%(p <  0.01) of patients and the mRS in 19.1%(p = 0.01). The usual activities dimension of the EQ-5D-3L showed a clinically relevant improvement after 1 year in 15.9%(p = 0.23) of patients.

CONCLUSIONS

A significant percentage of patients show improvements in some functional areas and in disability between 90 days and 1 year post-stroke.

Disability-Adjusted Life-Years Associated With Intracerebral Hemorrhage and Secondary Injury

Importance

Intracerebral hemorrhage (ICH) contributes significantly to the global burden of disease.

Objective

To examine the association of ICH and secondary injury with disability-adjusted life-years (DALYs) for the individual patient.

Design, Setting, and Participants

This cohort study was conducted using data from the Universitätsklinikum Erlangen Cohort of Patients With Spontaneous Intracerebral Hemorrhage study. Consecutive patients admitted to a single tertiary care center from January 1, 2006, to December 31, 2015, were included. The sample comprised patients with oral anticoagulation-associated ICH (OAC-ICH) or primary spontaneous ICH (non-OAC-ICH). Statistical analysis was conducted from October 1 to December 31, 2020.

Exposures

ICH occurrence and secondary injury.

Main Outcomes and Measures

DALYs, years of life lost (YLL), and years lived with disability (YLD) were analyzed by hematoma location, ICH volume, and secondary injury (ie, hematoma expansion [HE], intraventricular hemorrhage [IVH], and perihemorrhagic edema [PHE]).

Results

Among 1322 patients with ICH, 615 (46.5%) were women and the mean (SD) age at hospital admission was 71 (13) years; ICH was associated with a mean (SD) of 9.46 (8.08) DALYs, 5.72 (8.29) YLL, and 3.74 (5.95) YLD. There were statistically significant differences in mean (SD) DALYs by extent of hematoma volume (< 10 mL ICH: 7.05 [6.79] DALYs; 10-30 mL ICH: 9.91 [8.35] DALYs; >30 mL ICH: 12.42 [8.47] DALYs; P < .001) and ICH location (deep location: 10.60 [8.35] DALYs; lobar location: 8.18 [7.63] DALYs; cerebellum: 8.14 [6.80] DALYs; brainstem: 12.63 [9.21] DALYs; P < .001). Regarding population-level disease burden of secondary injuries after ICH, there was a statistically significant difference in mean (SD) by injury type, with 0.94 (3.19) DALYs for HE, 2.45 (4.16) DALYs for IVH, and 1.96 (2.66) DALYs for PHE (P < .001) among the entire ICH cohort. Regarding individual-level exposure to secondary injuries after ICH, there were a mean (SD) 7.14 (6.62) DALYs for HE, 4.58 (4.75) DALYs for IVH, and 3.35 (3.28) DALYs for PHE among patients with ICH affected by secondary injuries.

Conclusions and Relevance

These findings suggest that there is a high burden of disability associated with ICH and secondary injuries, and the findings may guide public health strategies. The study findings further suggest that IVH and PHE may be relevant for the overall outcome of patients with ICH, that DALYs may represent a viable outcome parameter for studies to evaluate treatment outcomes in ICH research, and that IVH and PHE may represent potential treatment targets.

Healthy Life-Year Costs of Treatment Speed From Arrival to Endovascular Thrombectomy in Patients With Ischemic Stroke: A Meta-analysis of Individual Patient Data From 7 Randomized Clinical Trials

Importance

The benefits of endovascular thrombectomy (EVT) are time dependent. Prior studies may have underestimated the time-benefit association because time of onset is imprecisely known.

Objective

To assess the lifetime outcomes associated with speed of endovascular thrombectomy in patients with acute ischemic stroke due to large-vessel occlusion (LVO).

Data Sources

PubMed was searched for randomized clinical trials of stent retriever thrombectomy devices vs medical therapy in patients with anterior circulation LVO within 12 hours of last known well time, and for which a peer-reviewed, complete primary results article was published by August 1, 2020.

Study Selection

All randomized clinical trials of stent retriever thrombectomy devices vs medical therapy in patients with anterior circulation LVO within 12 hours of last known well time were included.

Data Extraction/Synthesis

Patient-level data regarding presenting clinical and imaging features and functional outcomes were pooled from the 7 retrieved randomized clinical trials of stent retriever thrombectomy devices (entirely or predominantly) vs medical therapy. All 7 identified trials published in a peer-reviewed journal (by August 1, 2020) contributed data. Detailed time metrics were collected including last known well-to-door (LKWTD) time; last known well/onset-to-puncture (LKWTP) time; last known well-to-reperfusion (LKWR) time; door-to-puncture (DTP) time; and door-to-reperfusion (DTR) time.

Main Outcomes and Measures

Change in healthy life-years measured as disability-adjusted life-years (DALYs). DALYs were calculated as the sum of years of life lost (YLL) owing to premature mortality and years of healthy life lost because of disability (YLD). Disability weights were assigned using the utility-weighted modified Rankin Scale. Age-specific life expectancies without stroke were calculated from 2017 US National Vital Statistics.

Results

Among the 781 EVT-treated patients, 406 (52.0%) were early-treated (LKWTP ≤4 hours) and 375 (48.0%) were late-treated (LKWTP >4-12 hours). In early-treated patients, LKWTD was 188 minutes (interquartile range, 151.3-214.8 minutes) and DTP 105 minutes (interquartile range, 76-135 minutes). Among the 298 of 380 (78.4%) patients with substantial reperfusion, median DTR time was 145.0 minutes (interquartile range, 111.5-185.5 minutes). Care process delays were associated with worse clinical outcomes in LKW-to-intervention intervals in early-treated patients and in door-to-intervention intervals in early-treated and late-treated patients, and not associated with LKWTD intervals, eg, in early-treated patients, for each 10-minute delay, healthy life-years lost were DTP 1.8 months vs LKWTD 0.0 months; P < .001. Considering granular time increments, the amount of healthy life-time lost associated with each 1 second of delay was DTP 2.2 hours and DTR 2.4 hours.

Conclusions and Relevance

In this study, care delays were associated with loss of healthy life-years in patients with acute ischemic stroke treated with EVT, particularly in the postarrival time period. The finding that every 1 second of delay was associated with loss of 2.2 hours of healthy life may encourage continuous quality improvement in door-to-treatment times.

Disease burden from COVID-19 symptoms among inpatients at the temporary military hospitals in Wuhan: a retrospective multicentre cross-sectional study

OBJECTIVES

We aimed to establish a set of disability weights (DWs) for COVID-19 symptoms, evaluate the disease burden of inpatients and analyse the characteristics and influencing factors of the disease.

DESIGN

This was a multicentre retrospective cross-sectional descriptive study.

SETTING

The medical records generated in three temporary military hospitals in Wuhan.

PARTICIPANTS

Medical records of 2702 inpatients generated from 5 February to 5 April 2020 were randomly selected for this study.

PRIMARY AND SECONDARY OUTCOME MEASURES

DWs of COVID-19 symptoms were determined by the person trade-off approach. The inpatients' medical records were analysed and used to calculate the disability-adjusted life years (DALYs). The mean DALY was evaluated across sex and age groups. The relationship between DALY and age, sex, body mass index, length of hospital stay, symptom duration before admission and native place was determined by multiple linear regression.

RESULTS

For the DALY of each inpatient, severe expiratory dyspnoea, mild cough and sore throat had the highest (0.399) and lowest (0.004) weights, respectively. The average synthetic DALY and daily DALY were 2.29±1.33 and 0.18±0.15 days, respectively. Fever and fatigue contributed the most DALY at 31.36%, whereas nausea and vomiting and anxiety and depression contributed the least at 7.05%. There were significant differences between sex and age groups in both synthetic and daily DALY. Age, body mass index, length of hospital stay and symptom duration before admission were strongly related to both synthetic and daily DALY.

CONCLUSIONS

Although the disease burden was higher among women than men, their daily disease burdens were similar. The disease burden in the younger population was higher than that in the older population. Treatment at the hospitals relieved the disease burden efficiently, while a delay in hospitalisation worsened it.

Drip-and-ship versus mothership for endovascular treatment of acute stroke: A comparative effectiveness analysis

BACKGROUND

Triage for suspected acute stroke has two main options: (1) transport to the closest primary stroke center (PSC) and then to the nearest comprehensive stroke center (CSC) (Drip-and-Ship) or (2) transport the patient to the nearest CSC, bypassing a closer PSC (mothership). The purpose was to evaluate the effectiveness of drip-and-ship versus mothership models for acute stroke patients.

METHODS

A Markov decision-analytic model was constructed. All model parameters were derived from recent medical literature. Our target population was adult patient with sudden onset of acute stroke within 8 h of onset over a one-year horizon. The primary outcome was quantified in terms of quality-adjusted-life-years (QALYs).

RESULTS

The base case scenario show that the drip-and-ship strategy has a slightly higher expected health benefit, 0.591 QALY, as compared to 0.586 QALY in the mothership strategy when the time to PSC is 30 min and to CSC is 65 min, although the difference in health benefit becomes minimal as the time to PSC increases towards 60 min. Multiple sensitivity analyses show that when both PSC and CSC are far from place of onset (>1.5 h away), drip-and-ship becomes the better strategy. Mothership strategy is favored by smaller difference between distances to PSC and CSC, shorter transfer time from PSC to CSC, and longer delay in reperfusion in CSC for transferred patients. Drip-and-ship is favored by the reverse.

CONCLUSION

Drip-and-ship has a slightly higher utility than mothership. This study assesses the complex issue of prehospital triage of acute stroke patients and can provide a framework for real-world data input.

Cost Effectiveness of Interhospital Transfer for Mechanical Thrombectomy of Acute Large Vessel Occlusion Stroke: Role of Predicted Recanalization Rates

BACKGROUND

Emergency interhospital transfer of patients with stroke with large vessel occlusion to a comprehensive stroke center for mechanical thrombectomy is resource-intensive and can be logistically challenging. Imaging markers may identify patients in whom intravenous thrombolysis (IVT) alone is likely to result in thrombus resolution, potentially rendering interhospital transfers unnecessary. Here, we investigate how predicted probabilities to achieve IVT-mediated recanalization affect cost-effectiveness estimates of interhospital transfer.

METHODS

We performed a health economic analysis comparing emergency interhospital transfer of patients with acute large vessel occlusion stroke after administration of IVT with a scenario in which patients also receive IVT but remain at the primary hospital. Results were stratified by clinical parameters, treatment delays, and the predicted probability to achieve IVT-mediated recanalization. Estimated 3-month outcomes were combined with a long-term probabilistic model to yield quality-adjusted life years (QALYs) and costs. Uncertainty was quantified in probabilistic sensitivity analyses.

RESULTS

Depending on input parameters, marginal costs of interhospital transfer ranged from USD -61 366 (cost saving) to USD +20 443 and additional QALYs gained from 0.1 to 3.0, yielding incremental cost-effectiveness ratios of <USD 0 (dominant) to USD 310 000 per QALY. For some elderly patients with moderate or severe stroke symptoms treated in a remote primary stroke center, transfer was unlikely to be cost effective at a willingness-to-pay threshold of USD 100 000 and 50 000 per QALY (20% and 1%, respectively) if the predicted probability to achieve IVT-related recanalization was high. On the other hand, in some younger patients, the analysis yielded incremental cost-effectiveness ratio estimates below USD 20 000 per QALY independent of the predicted recanalization rate.

CONCLUSIONS

Predicted probabilities to achieve IVT-mediated recanalization significantly affect the cost-effectiveness of interhospital transfer for MT, in particular in elderly patients with moderate or severe stroke symptoms. However, high predicted recanalization rates alone do not generally imply that patients should not be considered for transfer.

Adjuvant High-Flow Normobaric Oxygen After Mechanical Thrombectomy for Anterior Circulation Stroke: a Randomized Clinical Trial

Adjuvant neuroprotective therapies for acute ischemic stroke (AIS) have demonstrated benefit in animal studies, albeit without human translation. We investigated the safety and efficacy of high-flow normobaric oxygen (NBO) after endovascular recanalization in anterior circulation stroke. This is a prospective randomized controlled study. Eligible patients were randomized to receive high-flow NBO by a Venturi mask (FiO2 50%, flow 15 L/min) or routine low-flow oxygen supplementation by nasal cannula (flow 3 L/min) after vessel recanalization for 6 h. Patient demographics, procedural metrics, complications, functional outcomes, symptomatic intracranial hemorrhage (sICH), and infarct volume were assessed. A total of 91 patients were treated with high-flow NBO. NBO treatment revealed a common odds ratio of 2.2 (95% CI, 1.26 to 3.87) favoring the distribution of global disability scores on the mRS at 90 days. The mortality at 90 days was significantly lower in the NBO group than in the control group, with an absolute difference of 13.86% (rate ratio, 0.35; 95% CI, 0.13-0.93). A significant reduction of infarct volume as determined by MRI was noted in the NBO group. The median infarct volume was 9.4 ml versus 20.5 ml in the control group (beta coefficient, - 20.24; 95% CI, - 35.93 to - 4.55). No significant differences were seen in the rate of sICH, pneumonia, urinary infection, and seizures between the 2 groups. This study suggests that high-flow NBO therapy after endovascular recanalization is safe and effective in improving functional outcomes, decreasing mortality, and reducing infarct volumes in anterior circulation stroke patients within 6 h from stroke onset.

Health-Related Quality of Life Among Patients With Acute Ischemic Stroke and Large Vessel Occlusion in the ESCAPE Trial

[Figure: see text].

Safety and efficacy of normobaric oxygenation on rescuing acute intracerebral hemorrhage-mediated brain damage-a protocol of randomized controlled trial

Background

All of the existing medication and surgical therapies currently cannot completely inhibit intracerebral hemorrhage (ICH)-mediated brain damage, resulting in disability in different degrees in the involved patients. Normobaric oxygenation (NBO) was reported attenuating ischemic brain injury. Herein, we aimed to explore the safety and efficacy of NBO on rescuing the damaged brain tissues secondary to acute ICH, especially those in the perihematoma area being threatened by ischemia and hypoxia.

Methods

A total of 150 patients confirmed as acute spontaneous ICH by computed tomography (CT) within 6 h after symptoms onset, will enroll in this study after signing the informed consent, and enter into the NBO group or control group randomly according to a random number. In the NBO group, patients will inhale high-flow oxygen (8 L/min, 1 h each time for 6 cycles daily) and intake low-flow oxygen (2 L/min) in intermittent periods by mask for a total of 7 days. While in the control group, patients will breathe in only low-flow oxygen (2 L/min) by mask for 7 consecutive days. Computed tomography and perfusion (CT/CTP) will be used to evaluate cerebral perfusion status and brain edema. CT and CTP maps in the two groups at baseline and day 7 and 14 after NBO or low-flow oxygen control will be compared. The primary endpoint is mRS at both Day14 post-ICH and the end of the 3rd month follow-up. The secondary endpoints include NIHSS and plasma biomarkers at baseline and Day-1, 7, and 14 after treatment, as well as the NIHSS at the end of the 3rd month post-ICH and the incidence of bleeding recurrence and the mortalities within 3 months post-ICH.

Discussion

This study will provide preliminary clinical evidence about the safety and efficacy of NBO on correcting acute ICH and explore some mechanisms accordingly, to offer reference for larger clinical trials in the future.

Trial registration

ClinicalTrials.gov NCT04144868. Retrospectively registered on October 29, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05048-4.

Reflections on key methodological decisions in national burden of disease assessments

BACKGROUND

Summary measures of population health are increasingly used in different public health reporting systems for setting priorities for health care and social service delivery and planning. Disability-adjusted life years (DALYs) are one of the most commonly used health gap summary measures in the field of public health and have become the key metric for quantifying burden of disease (BoD). BoD methodology is, however, complex and highly data demanding, requiring a substantial capacity to apply, which has led to major disparities across researchers and nations in their resources to perform themselves BoD studies and interpret the soundness of available estimates produced by the Global Burden of Disease Study.

METHODS

BoD researchers from the COST Action European Burden of Disease network reflect on the most important methodological choices to be made when estimating DALYs. The paper provides an overview of eleven methodological decisions and challenges drawing on the experiences of countries working with BoD methodology in their own national studies. Each of these steps are briefly described and, where appropriate, some examples are provided from different BoD studies across the world.

RESULTS

In this review article we have identified some of the key methodological choices and challenges that are important to understand when calculating BoD metrics. We have provided examples from different BoD studies that have developed their own strategies in data usage and implementation of statistical methods in the production of BoD estimates.

CONCLUSIONS

With the increase in national BoD studies developing their own strategies in data usage and implementation of statistical methods in the production of BoD estimates, there is a pressing need for equitable capacity building on the one hand, and harmonization of methods on the other hand. In response to these issues, several BoD networks have emerged in the European region that bring together expertise across different domains and professional backgrounds. An intensive exchange in the experience of the researchers in the different countries will enable the understanding of the methods and the interpretation of the results from the local authorities who can effectively integrate the BoD estimates in public health policies, intervention and prevention programs.

Reduced Impact of Endovascular Thrombectomy on Disability in Real-World Practice, Relative to Randomized Controlled Trial Evidence in Australia

Background and Aims: Disability-adjusted life years (DALYs) are an important measure of the global burden of disease that informs patient outcomes and policy decision-making. Our study aimed to compare the DALYs saved by endovascular thrombectomy (EVT) in the Australasian-based EXTEND-IA trial vs. clinical registry data from EVT in Australian routine clinical practice.

Methods: The 3-month modified Rankin scale (mRS) outcome and treatment status of consecutively enrolled Australian patients with large vessel occlusion (LVO) stroke were taken from the International Stroke Perfusion Imaging Registry (INSPIRE). DALYs were calculated as the summation of years of life lost (YLL) due to premature death and years lived with a disability (YLD). A generalized linear model (GLM) with gamma family and log link was used to compare the difference in DALYs for patients receiving/not receiving EVT while controlling for key covariates. Ordered logit regression model was utilized to compare the difference in functional outcome at 3 months between the treatment groups. Cox regression analysis was undertaken to compare the difference in survival over an 18-year time horizon. Estimated long-term DALYs saved based on the EXTEND-IA randomized controlled trial (RCT) results were used as the comparator.

Results: INSPIRE patients who received EVT treatment only achieved nominally better functional outcomes than the non-EVT group (p = 0.181) at 3 months. There was no significant survival gain from EVT over the first 3 months of stroke in both INSPIRE and EXTEND-IA patients. However, measured against no EVT in the long-term, EVT in INSPIRE was associated with no significant survival gain [hazard ratio (HR): 0.92, 95% confidence interval (CI): 0.78–1.08, p = 0.287] compared with the survival benefit extrapolated from the EXTEND-IA trial (HR: 0.42, 95% CI: 0.22–0.82, p = 0.01]. Offering EVT to patients with LVO stroke was also associated with fewer DALYs lost (11.04, 95% CI: 10.45–11.62) than those not receiving EVT in INSPIRE (12.13, 95% CI: 11.75–12.51), a reduction of −1.09 DALY (95% CI: −1.76 to −0.43, p = 0.002). The absolute magnitude of the treatment effect was lower than that seen in EXTEND-IA (−2.72 DALY reduction in EVT vs non-EVT patients).

Conclusions: EVT for the treatment of LVO in a registry of routine care was associated with significantly lower DALYs lost than medical care alone, but the saved DALYs are less than those reported in clinical trials, as there were major differences in the baseline characteristics of the patients.

The multiarm optimization of stroke thrombolysis phase 3 acute stroke randomized clinical trial: Rationale and methods

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.

Cost-Effectiveness of Tenecteplase Before Thrombectomy for Ischemic Stroke

Background and Purpose:

Tenecteplase improved functional outcomes and reduced the requirement for endovascular thrombectomy in ischemic stroke patients with large vessel occlusion in the EXTEND-IA TNK randomized trial. We assessed the cost-effectiveness of tenecteplase versus alteplase in this trial.

Methods:

Post hoc within-trial economic analysis included costs of index emergency department and inpatient stroke hospitalization, rehabilitation/subacute care, and rehospitalization due to stroke within 90 days. Sources for cost included key study site complemented by published literature and government websites. Quality-adjusted life-years were estimated using utility scores derived from the modified Rankin Scale score at 90 days. Long-term modeled cost-effectiveness analysis used a Markov model with 7 health states corresponding to 7 modified Rankin Scale scores. Probabilistic sensitivity analyses were performed.

Results:

Within the 202 patients in the randomized controlled trial, total cost was nonsignificantly lower in the tenecteplase-treated patients (40 997 Australian dollars [AUD]) compared with alteplase-treated patients (46 188 AUD) for the first 90 days( P =0.125). Tenecteplase was the dominant treatment strategy in the short term, with similar cost (5412 AUD [95% CI, −13 348 to 2523]; P =0.181) and higher benefits (0.099 quality-adjusted life-years [95% CI, 0.001–0.1967]; P =0.048), with a 97.4% probability of being cost-effective. In the long-term, tenecteplase was associated with less additional lifetime cost (96 357 versus 106 304 AUD) and greater benefits (quality-adjusted life-years, 7.77 versus 6.48), and had a 100% probability of being cost-effective. Both deterministic sensitivity analysis and probabilistic sensitivity analyses yielded similar results.

Conclusions:

Both within-trial and long-term economic analyses showed that tenecteplase was highly likely to be cost-effective for patients with acute stroke before thrombectomy. Recommending the use of tenecteplase over alteplase could lead to a cost saving to the healthcare system both in the short and long term.

Registration:

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02388061.