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Chong JSX, Phillips T, Massarotto A, Ghia D. Outcomes of endovascular thrombectomy for ischaemic stroke among nonagenarians with and without pre-existing dependency. J Stroke Cerebrovasc Dis 2024; 33:107722. [PMID: 38616014 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 04/03/2024] [Accepted: 04/11/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Our aim was to compare the outcomes of treatment with endovascular thrombectomy for pre-stroke dependent versus pre-stroke independent among the very elderly ≥90 years. METHODS A retrospective cohort study was performed on 106 patients ≥90 years who underwent endovascular thrombectomy for ischaemic stroke in Western Australia between June 2016 and September 2021. Patient, stroke and procedural details along with inpatient progress and outcome at 90 days were recorded. Patients were divided into Group A (pre-stroke modified Rankin Scale 0-2) and Group B (pre-stroke modified Rankin Scale >2). Primary outcome measure was functional status at 90 days post-stroke, with favourable clinical outcome defined as a 90-day mRS category equal to the patients' respective pre-stroke mRS category. Secondary outcome measures include successful reperfusion, symptomatic intracranial haemorrhage, hospital length-of-stay, change in accommodation to an aged care facility, and mortality during admission, at 90 days and one year. RESULTS 61 patients were allocated to Group A and 45 to Group B. There was none with pre-stroke mRS 5. Group B had more pre-existing cognitive impairment, aged care facility residents, higher median age and lower Alberta Stroke Program Early CT Score. For primary outcome measure, 38 % of patients in Group A and 49 % in Group B achieved a favourable clinical outcome. The difference was not significant (p=0.3408). For secondary outcome measures, Group B had a significantly higher 90-day mortality rate at 47 % versus 24 % in Group A (p=0.03). All other secondary outcome measures were similar between the two groups. These include the rate of successful reperfusion and symptomatic intracranial haemorrhage, hospital length-of-stay, new transition into an aged care facility, inpatient mortality rate and 1-year mortality rate. CONCLUSION When treated with endovascular thrombectomy for ischaemic stroke, nonagenarians with pre-existing dependency achieved a rate of favourable functional outcome comparable with their independent peers, although they also had higher 90-day mortality rate.
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Affiliation(s)
| | - Timothy Phillips
- Interventional Neuroradiologist, Neurological Intervention & Imaging Service of WA, Australia.
| | | | - Darshan Ghia
- Fiona Stanley Hospital, and Senior Clinical Lecturer, University of Western Australia, Australia.
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Nozoe M, Miyata K, Kubo H, Ishida M, Yamamoto K. Establishing minimal clinically important differences and cut-off values for the lower limb motricity index and trunk control test in older patients with acute stroke: a prospective cohort study. Top Stroke Rehabil 2024:1-10. [PMID: 38814857 DOI: 10.1080/10749357.2024.2359340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 05/18/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVE To establish the Minimal Clinically Important Differences (MCIDs) for lower limb strength measured by the Motricity Index (LLMI) and trunk function assessed by the Trunk Control Test (TCT) in the acute phase of stroke in older patients. Further, the study sought to determine the cutoff values predicting functional prognosis at discharge for both the LLMI and TCT. METHODS This prospective cohort study was conducted for older patients (≥65 years) admitted for acute stroke, receiving guideline-based stroke care that includes early rehabilitation. The LLMI and TCT were measured within 7 days of admission and at discharge. The MCID was derived from receiving operating characteristic curves, based on a ≥ 1 point shift in the modified Rankin Scale (mRS) from admission to discharge. A good functional prognosis at discharge was defined as an mRS score of ≤ 3. RESULTS A total of 201 older patients with acute stroke were included. The TCT achieved an MCID of 13 (area under the curve [AUC] = 0.704, 95% confidence interval [CI]: 0.633-0.775), whereas the LLMI lacked the precision to produce a significant MCID. The optimal cutoff points for predicting a good outcome were found to be an LLMI score of 65 (AUC = 0.770, 95% CI: 0.705-0.835) and a TCT score of 25 (AUC = 0.827, 95% CI: 0.768-0.887) upon admission. CONCLUSIONS This study identified a valid MCID for the TCT, failed to do so for the LLMI, and established cutoff values for both the LLMI and TCT that can predict good outcomes in older patients with acute stroke.
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Affiliation(s)
- Masafumi Nozoe
- Department of Physical Therapy, Faculty of Rehabilitation, Kansai Medical University, Osaka, Japan
| | - Kazuhiro Miyata
- Department of Physical Therapy, Ibaraki Prefectural University of Health Science, Ibaraki, Japan
| | - Hiroki Kubo
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women's University, Kobe, Japan
| | - Mitsuru Ishida
- Department of Rehabilitation, Konan Medical Center, Kobe, Japan
| | - Kenta Yamamoto
- Department of Rehabilitation, Konan Medical Center, Kobe, Japan
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Maestrini I, Rocchi L, Diana F, Requena Ruiz M, Elosua-Bayes I, Ribo M, Abdalkader M, Klein P, Gabrieli JD, Alexandre AM, Pedicelli A, Lacidogna G, Ciullo I, Marnat G, Cester G, Broccolini A, Nguyen TN, Tomasello A, Garaci F, Diomedi M, Da Ros V. Outcomes and safety of endovascular treatment from 6 to 24 hours in patients with a pre-stroke moderate disability (mRS 3): a multicenter retrospective study. J Neurointerv Surg 2024:jnis-2024-021634. [PMID: 38811146 DOI: 10.1136/jnis-2024-021634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 04/13/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Approximately 30% of patients presenting with acute ischemic stroke (AIS) due to large vessel occlusion have pre-stroke modified Rankin Scale (mRS) scores ≥2. We aimed to investigate the safety and outcomes of endovascular treatment (EVT) in patients with AIS with moderate pre-stroke disability (mRS score 3) in an extended time frame (ie, 6-24 hours from the last time known well). METHODS Data were collected from five centers in Europe and the USA from January 2018 to January 2023 and included 180 patients who underwent EVT in an extended time frame. Patients were divided into two groups of 90 each (Group 1: pre-mRS 0-2; Group 2: pre-mRS 3; 71% women, mean age 80.3±11.9 years). Primary outcomes were: (1) 3-month good clinical outcome (Group 1: mRS 0-2, Group 2: mRS 0-3) and ΔmRS; (2) any hemorrhagic transformation (HT); and (3) symptomatic HT. Secondary outcomes were successful and complete recanalization after EVT and 3-month mortality. RESULTS No between-group differences were found in the 3-month good clinical outcome (26.6% vs 25.5%, P=0.974), any HT (26.6% vs 22%, P=0.733), and symptomatic HT (8.9 vs 4.4%, P=0.232). Unexpectedly, ΔmRS was significantly smaller in Group 2 compared with Group 1 (1.64±1.61 vs 2.97±1.69, P<0.001). No between-group differences were found in secondary outcomes. CONCLUSION Patients with pre-stroke mRS 3 are likely to have similar outcomes after EVT in the extended time frame to those with pre-stroke mRS 0-2, with no difference in safety.
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Affiliation(s)
- Ilaria Maestrini
- Stroke Center, Department of Systems Medicine, University Hospital of Rome Tor Vergata, Rome, Italy
| | - Lorenzo Rocchi
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Francesco Diana
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
- Stroke Research group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Manuel Requena Ruiz
- Stroke Research group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Iker Elosua-Bayes
- Stroke Research group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marc Ribo
- Stroke Research group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Mohamad Abdalkader
- Diagnostic and Interventional Neuroradiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Piers Klein
- Diagnostic and Interventional Neuroradiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Joseph D Gabrieli
- Department of Neuroradiology, University Hospital of Padova, Padua, Italy
| | - Andrea M Alexandre
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
| | - Alessandro Pedicelli
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
- Catholic University School of Medicine, Institute of Bio-Imaging, Rome, Italy
| | - Giordano Lacidogna
- Stroke Center, Department of Systems Medicine, University Hospital of Rome Tor Vergata, Rome, Italy
| | - Ilaria Ciullo
- Stroke Center, Department of Systems Medicine, University Hospital of Rome Tor Vergata, Rome, Italy
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Giacomo Cester
- Department of Neuroradiology, University Hospital of Padova, Padua, Italy
| | - Aldobrando Broccolini
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Thanh N Nguyen
- Diagnostic and Interventional Neuroradiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Alejandro Tomasello
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
- Stroke Research group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Francesco Garaci
- Neuroradiology Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Marina Diomedi
- Stroke Center, Department of Systems Medicine, University Hospital of Rome Tor Vergata, Rome, Italy
| | - Valerio Da Ros
- Neuroradiology Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
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Tanaka K, Yamagami H, Qureshi MM, Uchida K, Siegler JE, Nogueira RG, Yoshimura S, Sakai N, Martinez-Majander N, Nagel S, Demeestere J, Puetz V, Haussen DC, Abdalkader M, Olive-Gadea M, Mohammaden MH, Marto JP, Dusart A, Winzer S, Tomppo L, Caparros F, Henon H, Bellante F, Ramos JN, Ortega-Gutierrez S, Sheth SA, Nannoni S, Kaesmacher J, Vandewalle L, Salazar-Marioni S, Farooqui M, Virtanen P, Ventura R, Zaidi S, Castonguay AC, Puri AS, Farzin B, Masoud HE, Klein P, Jesser J, Requena M, Dobrocky T, Kaiser DP, Peltola E, Strambo D, Möhlenbruch MA, Lin E, Ringleb PA, Zaidat OO, Cordonnier C, Roy D, Lemmens R, Ribo M, Strbian D, Fischer U, Michel P, Raymond J, Nguyen TN. Endovascular Therapy in the Extended Time Window for Large Vessel Occlusion in Patients With Pre-Stroke Disability. J Stroke 2024; 26:269-279. [PMID: 38836274 PMCID: PMC11164586 DOI: 10.5853/jos.2023.04259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/24/2024] [Accepted: 02/13/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND PURPOSE We compared the outcomes of endovascular therapy (EVT) in an extended time window in patients with large-vessel occlusion (LVO) between patients with and without pre-stroke disability. METHODS In this prespecified analysis of the multinational CT for Late Endovascular Reperfusion study (66 participating sites, 10 countries between 2014 and 2022), we analyzed data from patients with acute ischemic stroke with a pre-stroke modified Rankin Scale (mRS) score of 0-4 and LVO who underwent EVT 6-24 hours from the time last seen well. The primary outcome was the composite of functional independence (FI; mRS score 0-2) or return to the pre-stroke mRS score (return of Rankin, RoR) at 90 days. Outcomes were compared between patients with pre-stroke disability (pre-stroke mRS score 2-4) and those without (mRS score 0-1). RESULTS A total of 2,231 patients (median age, 72 years; median National Institutes of Health Stroke Scale score, 16) were included in the present analysis. Of these, 564 (25%) had pre-stroke disability. The primary outcome (FI or RoR) was observed in 30.7% of patients with pre-stroke disability (FI, 16.5%; RoR, 30.7%) compared to 44.1% of patients without (FI, 44.1%; RoR, 13.0%) (P<0.001). In multivariable logistic regression analysis with inverse probability of treatment weighting, pre-stroke disability was not associated with significantly lower odds of achieving FI or RoR (adjusted odds ratio 0.73, 95% confidence interval 0.43-1.25). Symptomatic intracranial hemorrhage occurred in 6.3% of both groups (P=0.995). CONCLUSION A considerable proportion of patients with late-presenting LVO and pre-stroke disability regained pre-stroke mRS scores after EVT. EVT may be appropriate for patients with pre-stroke disability presenting in the extended time window.
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Affiliation(s)
- Kanta Tanaka
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan
- Stroke Center, Kindai University Hospital, Osakasayama, Japan
| | - Hiroshi Yamagami
- Division of Stroke Prevention and Treatment, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Muhammad M. Qureshi
- Department of Radiology, Radiation Oncology, Boston Medical Center, Boston, MA, USA
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - James E. Siegler
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Raul G. Nogueira
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical General Hospital, Kobe, Japan
| | | | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Heidelberg University Hospital, Ludwigshafen, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jelle Demeestere
- Department of Neurology, Leuven University Hospital, Leuven, Belgium
| | - Volker Puetz
- Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Diogo C. Haussen
- Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | | | | | - João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Anne Dusart
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Simon Winzer
- Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Liisa Tomppo
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Francois Caparros
- Department of Neurology, Centre Hospitalier Universitaire de Lille, University of Lille, Lille, France
| | - Hilde Henon
- Department of Neurology, Centre Hospitalier Universitaire de Lille, University of Lille, Lille, France
| | - Flavio Bellante
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - João Nuno Ramos
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | | | - Sunil A. Sheth
- Department of Neurology, UTHealth Houston, Houston, TX, USA
| | - Stefania Nannoni
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | | | | | | | - Pekka Virtanen
- Department of Radiology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Rita Ventura
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Syed Zaidi
- Department of Neurology, University of Toledo, Toledo, OH, USA
| | | | - Ajit S. Puri
- Division of Interventional Neuroradiology, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Behzad Farzin
- Department of Radiology, Centre Hospitalier de l’Universite de Montreal, Montreal, Canada
| | - Hesham E. Masoud
- Department of Neurology, State University of New York, Upstate Medical University, Syracuse, NY, USA
| | - Piers Klein
- Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Jessica Jesser
- Department of Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Manuel Requena
- Department of Neurology, Hospital Vall d’Hebron, Barcelona, Spain
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Daniel P.O. Kaiser
- Department of Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Erno Peltola
- Department of Radiology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Davide Strambo
- Department of Neurology, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Eugene Lin
- Neuroscience and Stroke Program, Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH, USA
| | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Osama O. Zaidat
- Neuroscience and Stroke Program, Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH, USA
| | - Charlotte Cordonnier
- Department of Neurology, Centre Hospitalier Universitaire de Lille, University of Lille, Lille, France
| | - Daniel Roy
- Department of Radiology, Centre Hospitalier de l’Universite de Montreal, Montreal, Canada
| | - Robin Lemmens
- Department of Neurology, Leuven University Hospital, Leuven, Belgium
| | - Marc Ribo
- Department of Neurology, Hospital Vall d’Hebron, Barcelona, Spain
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Urs Fischer
- Department of Neurology, University Hospital Basel, Switzerland
- Department of Neurology, University Hospital Bern, Switzerland
| | - Patrik Michel
- Department of Neurology, Lausanne University Hospital, Lausanne, Switzerland
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l’Universite de Montreal, Montreal, Canada
| | - Thanh N. Nguyen
- Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
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Jia WL, Jiang YY, Jiang Y, Meng X, Li H, Zhao XQ, Wang YL, Wang YJ, Gu HQ, Li ZX. Associations between admission levels of multiple biomarkers and subsequent worse outcomes in acute ischemic stroke patients. J Cereb Blood Flow Metab 2024; 44:742-756. [PMID: 37975323 DOI: 10.1177/0271678x231214831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
The modified Rankin Scale change score (ΔmRS) is useful for evaluating acute poststroke functional improvement or deterioration. We investigated the relationship between multiple biomarkers and ΔmRS by analyzing data on 6931 patients with acute ischemic stroke (average age 62.3 ± 11.3 years, 2174 (31.4%) female) enrolled from the Third China National Stroke Registry (CNSR-III) and 15 available biomarkers. Worse outcomes at 3 months were defined as ΔmRS3m-discharge ≥1 (ΔmRS3m-discharge = mRS3m-mRSdischarge). Adjusted odds ratios (aORs) and their 95% confidence intervals (CIs) were calculated from logistic regression models. At 3-months poststroke, 1026 (14.8%) patients experienced worse outcomes. The highest quartiles of white blood cells (WBCs) (aOR [95%CI],1.37 [1.12-1.66]), high-sensitivity C-reactive protein (hs-CRP) (1.37 [1.12-1.67]), interleukin-6 (IL-6) (1.43 [1.16-1.76]), interleukin-1 receptor antagonist (IL-1Ra) (1.46 [1.20-1.78]) and YKL-40 (1.31 [1.06-1.63]) were associated with an increased risk of worse outcomes at 3 months. Results remained stable except for YKL-40 when simultaneously adding multiple biomarkers to the basic traditional-risk-factor model. Similar results were observed at 6 and 12 months after stroke. This study indicated that WBCs, hs-CRP, IL-6, IL-1Ra, and YKL-40 were significantly associated with worse outcomes in acute ischemic stroke patients, and all inflammatory biomarkers except YKL-40 were independent predictors of worse outcomes at 3 months.
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Affiliation(s)
- Wei-Li Jia
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying-Yu Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xing-Quan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi-Long Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yong-Jun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Hong-Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zi-Xiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
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Nozoe M, Inoue T, Ogino T, Okuda K, Yamamoto K. The added value of frailty assessment as the premorbid stroke status on activities of daily living in patients with acute stroke, stratified by stroke severity. J Nutr Health Aging 2024; 28:100201. [PMID: 38460317 DOI: 10.1016/j.jnha.2024.100201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/10/2024] [Accepted: 02/11/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND The modified Rankin scale (mRS) is extensively used for premorbid evaluation in patients with stroke; however, its limited capacity to assess functional status highlights the need for additional indicators such as frailty. AIMS This study aimed to assess the impact of the premorbid mRS score and frailty on daily living (ADL) activities at hospital discharge, focusing on varying stroke severities. METHODS This single-centre, prospective cohort study included patients with acute stroke aged ≥60 years. Key metrics included the frailty index for frailty assessment or mRS for functional status premorbid and the functional independence measure of the motor domain (FIM-M) at discharge for ADL outcomes. The patients were categorized into mild (0-4), moderate (5-15), and severe (16-42) groups based on the National Institute of Health Stroke Scale. Multiple hierarchical linear regression analyses were performed for each group to evaluate the influence of mRS and frailty on FIM-M scores. RESULTS In the mild stroke group, significant associations were observed with premorbid mRS3 (β = -0.183, p = 0.004), mRS4 (β = -0.234, p < 0.001), and frailty status (β = -0.227, p = 0.005) and FIM-M scores. Premorbid frailty did not show a significant association with the FIM-M scores in the moderate or severe stroke group. Frailty status notably contributed to changes in R², particularly in the mild stroke group (R² change = 0.031, p = 0.002). However, such changes were not evident in the other stroke severity groups. CONCLUSION This study emphasizes the importance of incorporating frailty assessments into premorbid evaluations, particularly when considering ADL outcomes in patients with mild stroke. Conversely, the significance of frailty in moderate-to-severe stroke was less evident.
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Affiliation(s)
- Masafumi Nozoe
- Department of Physical Therapy, Faculty of Rehabilitation, Kansai Medical University, Osaka, Japan.
| | - Tatsuro Inoue
- Department of Physical Therapy, Niigata University of Health and Welfare, Niigata, Japan
| | - Tomoyuki Ogino
- Department of Physical Therapy,Faculty of Rehabilitation, Hyogo Medical University, Kobe, Japan
| | - Kazuki Okuda
- Department of Rehabilitation, Konan Medical Center, Kobe, Japan
| | - Kenta Yamamoto
- Department of Rehabilitation, Konan Medical Center, Kobe, Japan
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7
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Meyer AC, Ebeling M, Modig K. Trajectories of Long-term Care after Stroke in Sweden: Nationwide Study Exploring Patterns and Determinants. J Am Med Dir Assoc 2024; 25:599-605.e5. [PMID: 38184296 DOI: 10.1016/j.jamda.2023.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 01/08/2024]
Abstract
OBJECTIVES Stroke is a leading cause of mortality and disability worldwide. Although studies have primarily focused on health and functioning among stroke survivors, there is limited research on longitudinal patterns of long-term care use among older adults with stroke. This study explores long-term care trajectories among older men and women with stroke in the Swedish population. DESIGN Nationwide prospective cohort study. SETTING AND PARTICIPANTS All individuals aged ≥70 years hospitalized with a first stroke in 2015-2017 followed in the Swedish population registers for 3 years. METHODS Care trajectories among patients with strokes were visualized and compared to trajectories in 2 control groups: (1) same-aged peers randomly drawn from the general population and (2) older adults with health and sociodemographic characteristics similar to patients with strokes but without stroke identified through propensity score matching. Multivariable Cox regression and multistate models were used to identify determinants of mortality and care trajectories among patients with strokes. RESULTS We identified 31,560 individuals with stroke (mean age 82.9 years). Already before the stroke, these individuals had a higher comorbidity burden and received more long-term care than their same-aged peers. Compared with both control groups, patients with strokes were also more likely to enter long-term care. However, 38% of patients with strokes survived for 3 years without taking up long-term care. Sex, income, cohabitation, and comorbidities were associated with care trajectories. Care status was a more robust predictor of mortality after stroke than the established Charlson comorbidity index. CONCLUSIONS AND IMPLICATIONS Experiencing a stroke increases both mortality and long-term care utilization, and once formal long-term care is provided, exceedingly few patients with strokes return to living without care. However, a considerable part of care utilization and mortality after stroke is concentrated among those with preexisting care needs. Prestroke care utilization should thus be considered in future studies exploring stroke prognosis.
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Affiliation(s)
- Anna C Meyer
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Marcus Ebeling
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Laboratory of Population Health, Max Planck Institute for Demographic Research, Rostock, Germany
| | - Karin Modig
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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Ogino T, Nozoe M, Inoue T, Ishida M, Yamamoto K. Impact of possible sarcopenia on functional prognosis in patients with acute stroke with premorbid disability. Geriatr Gerontol Int 2024; 24:359-363. [PMID: 38410028 DOI: 10.1111/ggi.14840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/18/2024] [Accepted: 02/07/2024] [Indexed: 02/28/2024]
Abstract
AIM How possible sarcopenia affects functional prognosis in patients with premorbid disability remains unclear. This study aimed to compare and investigate the impact of possible sarcopenia at admission on functional outcomes at discharge in patients with acute stroke with and without premorbid disability. METHODS This cohort study enrolled patients who were consecutively admitted to a single center for acute stroke. Calf circumference and grip strength were measured within 7 days of admission, and possible sarcopenia was determined using the Asian Working Group for Sarcopenia 2019 criteria. The Functional Independence Measure (FIM) score at discharge during the acute phase was the primary outcome. To examine the impact of possible sarcopenia on FIM scores at discharge, patients were divided into two groups according to being with or without premorbid disability according to the modified Rankin Scale, and multiple linear regression analysis was performed in each group. RESULTS This study included 456 patients with acute stroke (median age, 80 years). In the premorbid-disability group (n = 166), possible sarcopenia was present in 140 patients (84%). Patients without possible sarcopenia had significantly higher FIM scores at discharge compared with those with possible sarcopenia (P < 0.001). However, multiple linear regression analysis showed that possible sarcopenia was not associated with FIM scores at discharge in the premorbid-disability group (β = -0.054, P = 0.346). CONCLUSIONS The results of this study demonstrated that a high rate of possible sarcopenia was observed in patients with stroke with premorbid disability; however, this did not affect functional prognosis. Geriatr Gerontol Int 2024; 24: 359-363.
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Affiliation(s)
- Tomoyuki Ogino
- Department of Physical Therapy, School of Rehabilitation, Hyogo Medical University, Kobe, Japan
| | - Masafumi Nozoe
- Department of Physical Therapy, School of Rehabilitation, Kansai Medical University, Hirakata, Japan
| | - Tatsuro Inoue
- Department of Physical Therapy, Niigata University of Health and Welfare, Niigata, Japan
| | - Mitsuru Ishida
- Department of Rehabilitation, Konan Medical Center, Kobe, Japan
| | - Kenta Yamamoto
- Department of Rehabilitation, Konan Medical Center, Kobe, Japan
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Nozoe M, Kubo H, Yamamoto M, Ikeji R, Seike H, Majima K, Shimada S. Muscle weakness is more strongly associated with functional outcomes in patients with stroke than sarcopenia or muscle wasting: an observational study. Aging Clin Exp Res 2024; 36:4. [PMID: 38261059 PMCID: PMC10806041 DOI: 10.1007/s40520-023-02672-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 11/21/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Stroke-related sarcopenia is an important prognosis factor and an intervention target for improving outcomes in patients with stroke. AIM This study aimed to identify the association between sarcopenia, possible sarcopenia, muscle weakness, muscle mass and calf circumference, and the functional outcomes 3 months after stroke. METHODS In this single-centre prospective observational study, muscle strength, muscle mass, and calf circumference were measured in patients with acute stroke at hospital discharge. Diagnosis of sarcopenia, possible sarcopenia, muscle weakness, low muscle mass, and low calf circumference were defined according to the 2019 Asian Working Group for Sarcopenia criteria. The primary outcome measure was the modified Rankin Scale (mRS) score at 3 months, with an mRS score of 3 or higher indicating a poor outcome. Logistic regression analysis was conducted to examine independent associations between each assessment and functional outcomes. RESULTS A total of 247 patients (median age: 73 years) were included in this study. The prevalence of sarcopenia was 28% (n = 70), and in the adjusted model, sarcopenia (aOR = 2.60, 95% CI 1.07-6.31, p = 0.034), muscle weakness (aOR = 3.40, 95% CI 1.36-8.52, p = 0.009), and low muscle mass (aOR = 2.61, 95% CI 1.04-6.52) were significantly associated with poor functional outcome. Nevertheless, other evaluations did not demonstrate an independent association with the outcome. CONCLUSION Sarcopenia, muscle weakness, and low muscle mass were found to be independently associated with functional outcomes 3 months after stroke, and muscle weakness exhibited the strongest association with outcomes among them.
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Affiliation(s)
- Masafumi Nozoe
- Department of Physical Therapy, Faculty of Rehabilitation, Kansai Medical University, 18-89 Uyamahigashicho, Hirakata, Osaka, Japan.
| | - Hiroki Kubo
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women's University, Kobe, Japan
| | - Miho Yamamoto
- Department of Rehabilitation Medicine, Nishiyamato Rehabilitation Hospital, Nara, Japan
| | - Rio Ikeji
- Department of Rehabilitation, Itami Kousei Neurosurgical Hospital, Itami, Japan
| | - Haruka Seike
- Department of Rehabilitation, Itami Kousei Neurosurgical Hospital, Itami, Japan
| | - Kazuki Majima
- Department of Rehabilitation, Itami Kousei Neurosurgical Hospital, Itami, Japan
| | - Shinichi Shimada
- Department of Neurosurgery, Itami Kousei Neurosurgical Hospital, Itami, Japan
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10
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Bala F, Betzner W, Beland B, McDonald JS, Ganesh A. Reperfusion therapies for ischemic stroke in dementia and cognitive impairment: A systematic review and meta-analysis. Int J Stroke 2023:17474930231220186. [PMID: 38044328 DOI: 10.1177/17474930231220186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
BACKGROUND Endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) have an unclear benefit in those with pre-stroke dementia or cognitive impairment, as these patients were often excluded from landmark stroke trials. We performed a systematic review and meta-analysis to assess the outcomes of IVT and EVT in these populations. AIMS Our systematic review, conforming to the Meta-Analysis of Observational Studies in Epidemiology guidelines, investigated studies on acute ischemic stroke patients with pre-stroke dementia or cognitive impairment treated with IVT or EVT. Primary outcome was favorable 90-day outcome (mRS 0-2). Secondary outcomes included 90-day mortality, symptomatic intracranial hemorrhage (SICH), and radiographic intracranial hemorrhage (ICH). SUMMARY OF REVIEW Nine articles were identified, with five observational studies of IVT use in patients with (n = 1078) and without dementia (n = 2805) being selected for the meta-analysis. There were no significant differences in favorable outcome (adjusted OR: 0.61, 95% CI 0.24-1.59), mortality (unadjusted OR: 1.19, 95% CI 0.86-1.64), ICH (unadjusted OR: 1.32, 95% CI 0.79-2.19), and symptomatic ICH (unadjusted OR: 0.94, 95% CI 0.70-1.25) for patients undergoing IVT with pre-stroke dementia versus those without. One EVT study (n = 615 with dementia vs n = 9600 without) found no significant differences in outcomes apart from an increased odds of ICH for those with pre-existing dementia (adjusted OR: 1.57, 95% CI 1.03-2.40). A pooled analysis of three IVT studies showed no significant association of cognitive impairment (n = 93 vs n = 211 without) with all assessed outcomes, whereas a study of EVT found that pre-stroke cognitive impairment was associated with poor 90-day outcomes (mRS 3-6). CONCLUSION These results suggest no substantial safety issues in the use of IVT or EVT for patients with pre-existing dementia or cognitive impairment compared to those without. However, the efficacy of these therapies in this demographic remains uncertain. Further rigorous studies that include a more nuanced outcome measurement approach are warranted. REGISTRATION URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021240499.
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Affiliation(s)
- Fouzi Bala
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, France
| | - William Betzner
- Departments of Clinical Neurosciences and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Benjamin Beland
- Departments of Clinical Neurosciences and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Jennifer S McDonald
- Department of Radiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aravind Ganesh
- Departments of Clinical Neurosciences and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Matheson Centre for Mental Health Research and Education, O'Brien Institute for Public Health, Calgary, AB, Canada
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Dishman D, Lal T, Silos C, Chen L, Jiang X, Beauchamp J, Aggarwal S, Green C, Savitz SI. A retrospective examination of pain in acute stroke at hospital discharge. J Stroke Cerebrovasc Dis 2023; 32:107370. [PMID: 37832269 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/10/2023] [Accepted: 09/12/2023] [Indexed: 10/15/2023] Open
Abstract
OBJECTIVES Pain is an overlooked sequela of stroke. Persistent pain after stroke is an underrecognized experience and significantly impacts survivors' function, ability to participate in rehabilitation, and quality of life. The aim of this retrospective, observational study is to examine the incidence of pain at the acute hospitalization period immediately after stroke, to identify the characteristics of those reporting pain at discharge, and to compare pain reporting between stroke and non-stroke hospital controls. MATERIALS AND METHODS Using discharge diagnosis, this retrospective review examined self- reports of pain during acute hospitalization for stroke compared to those with COPD (control group) admitted during the same time in the same facilities. Variables of interest included age, gender, body mass index (BMI), length of stay, pain assessment score (numeric rating scale [NRS], behavior pain scale [BPS], and medication administration record pain score total [MAR]), smoking history, prevalence of hypertension and race. 821 subjects were included from a total of three campuses from one large hospital system. 772 subjects were included in the comparative analysis with COPD patients from the same facilities during the same time. RESULTS 43% of patients diagnosed with stroke reported pain at discharge. For stroke survivors reporting pain at discharge, the average BMI was higher (p=0.009), average arrival NIHSS was higher (p=0.044), and mean hospital length of stay was longer (p<0.001). CONCLUSIONS The evidence demonstrated in this study highlights the critical need for the implementation of targeted objective pain assessment and effective pain interventions for stroke survivors beginning at initial hospitalization.
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Affiliation(s)
- Deniz Dishman
- Institute for Stroke and Cerebrovascular Disease and Cizik School of Nursing, University of Texas Health Science Center at Houston, United States; Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, United States.
| | - Tia Lal
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, United States
| | - Christin Silos
- Baylor College of Medicine, Houston, Texas, United States
| | - Luyao Chen
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, United States
| | - Xiaoqian Jiang
- Institute for Stroke and Cerebrovascular Disease and School of Biomedical Informatics, University of Texas Health Science Center at Houston, United States
| | - Jennifer Beauchamp
- Institute for Stroke and Cerebrovascular Disease and Cizik School of Nursing, University of Texas Health Science Center at Houston, United States
| | - Seema Aggarwal
- Institute for Stroke and Cerebrovascular Disease and Cizik School of Nursing, University of Texas Health Science Center at Houston, United States
| | - Charles Green
- Institute for Stroke and Cerebrovascular Disease and McGovern Medical School, University of Texas Health Science Center at Houston, United States
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, United States
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12
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Cruise C, Mfoafo M'Carthy N, Ganesh A, Lashewicz B. Imperfect Patients: Disparities in Treatment of Stroke Patients with Premorbid Disability. Can J Neurol Sci 2023; 50:826-837. [PMID: 36503627 DOI: 10.1017/cjn.2022.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite the high proportion of stroke patients with a pre-existing impairment, patients with disabilities are often excluded from stroke treatment trials. Trials are designed for "perfect patients": patients who are functionally independent and thus generally younger with fewer comorbidities; ironically, such patients are less likely to experience stroke than those with premorbid disability. Exclusionary practices in trials may translate into disparities in stroke care in practice. Through a review of literature, our purpose is to illuminate how people with disabilities are treated across the care continuum following a stroke. METHODS We completed a qualitative systematized review of articles pertaining to the care of patients with premorbid disability and stroke and their outcomes. Using a critical disability studies' theoretical lens, we analyzed inequity across the stroke care continuum. FINDINGS Among 24 included studies, we found evidence that people with disabilities did not receive equitable access to treatment ranging from being admitted to stroke units to receiving post-stroke rehabilitation. However, observational studies suggest that stroke therapies may be beneficial in selected patients with disabilities when measures of success are framed more achievable (e.g. return to pre-stroke status). This leaves us concerned about how people with pre-existing impairments might be structurally disabled within current systems of stroke care. CONCLUSION We use our critical disability studies' theoretical lens to argue that an intersectional approach to stroke treatment is much needed if we are to remedy structural inequities embedded throughout the care continuum.
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Affiliation(s)
- Cera Cruise
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Nicole Mfoafo M'Carthy
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Bonnie Lashewicz
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
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Ruel S, Baptiste L, Duloquin G, Béjot Y. Functional outcomes of ischemic stroke patients aged over 80 years treated with acute revascularization therapy according to pre-morbid disability: a PARADISE study. Front Neurol 2023; 14:1186288. [PMID: 37426437 PMCID: PMC10325647 DOI: 10.3389/fneur.2023.1186288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/16/2023] [Indexed: 07/11/2023] Open
Abstract
Introduction Aging population leads to changes in the profile of patients with acute ischemic stroke (IS), and older adults were largely excluded from randomized clinical trials of acute revascularization therapy. This study aimed to assess functional outcomes of treated IS patients > 80 years old according to prior disability and identify associated factors. Methods Consecutively older patients with acute IS treated with either IV thrombolysis and/or mechanical thrombectomy were enrolled between 2016 and 2019. Pre-morbid disability was assessed using the modified Rankin Scale (mRS) score, and patients were classified as being independent (mRS score, 0-2) or having pre-existing disability (mRS score, 3-5). A multivariable logistic regression analysis was performed to assess factors associated with a poor functional outcome (mRS score > 3) at 3 and 12 months in each group of patients. Results Among 300 included patients (mean age: 86.3 ± 4.6 years, 63% women, median NIHSS score: 14, IQR: 8-19), 100 had a pre-existing disability. In patients with a pre-morbid mRS score of 0-2, 51% had mRS >3 including 33% of deaths at 3 months. At 12 months, 50% had a poor outcome including 39% of deaths. In patients with a pre-morbid mRS score of 3-5, 71% had a poor outcome at 3 months including 43% of deaths, and at 12 months, 76% had mRS >3 including 52% of deaths. In multivariable models, the NIHSS score at 24 h was independently associated with poor outcomes at 3 and 12 months in both patients with (OR = 1.32; 95% CI: 1.16-1.51, p < 0.001 for 12 months outcome) or without (OR = 1.31; 95% CI: 1.19-1.44, p < 0.001 for 12 months outcome) pre-morbid disability. Conclusion Although a large proportion of older patients with a pre-existing disability had a poor functional outcome, they did not differ from their non-impaired counterparts regarding prognostic factors. This means that there were no factors in our study that would help clinicians identify patients at risk of poor functional outcomes after revascularization therapy among those with prior disability. Further studies are needed to better understand the post-stroke trajectory of older IS patients with a pre-morbid disability.
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14
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Bala F, Beland B, Mistry E, Almekhlafi MA, Goyal M, Ganesh A. Endovascular treatment of acute ischemic stroke in patients with pre-morbid disability: a meta-analysis. J Neurointerv Surg 2023; 15:343-349. [PMID: 35292569 DOI: 10.1136/neurintsurg-2021-018573] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/06/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Trials of endovascular thrombectomy (EVT) for acute stroke have excluded patients with pre-morbid disability. Observational studies may help inform consideration of EVT in this population. We aimed to assess the effectiveness and safety of EVT in patients with pre-morbid disability. METHODS According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched MEDLINE and Embase for studies describing outcomes in patients with pre-morbid disability (modified Rankin Scale (mRS) 2-5), treated with EVT or medical management (MM). Random-effects meta-analysis was used to pool outcomes including 90-day return to baseline mRS, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. RESULTS We analyzed 14 studies of patients with pre-morbid disability (mRS 2-5, 1373 EVT and 253 MM). The rate of return to baseline mRS was 30.0% (95% CI 25.3% to 34.7%) in patients treated with EVT. Compared with medical therapy, EVT was associated with a higher likelihood of return to baseline mRS (OR 2.37, 95% CI 1.39 to 4.04) and a trend towards lower mortality (OR 0.68, 95% CI 0.46 to 1.02), with similar odds of sICH (OR 1.01, 95% CI 0.49 to 2.08). In studies comparing patients with versus without pre-morbid disability treated with EVT, similar results were found except that pre-morbid disability, when defined more strictly as mRS 3-5, was associated with mortality (OR 3.49, p<0.001). CONCLUSION In eligible patients with pre-morbid disability, observational studies suggest that EVT carries a higher chance of return to baseline mRS compared with patients treated with MM or without pre-morbid disability, although with higher mortality than patients without pre-morbid disability. These findings argue against the routine exclusion of such patients from EVT and merit validation with randomized trials.
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Affiliation(s)
- Fouzi Bala
- Calgary Stroke Program, Departments of Clinical Neurosciences, Community Health Sciences, and Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Benjamin Beland
- Calgary Stroke Program, Departments of Clinical Neurosciences, Community Health Sciences, and Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Eva Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Mohammed A Almekhlafi
- Calgary Stroke Program, Departments of Clinical Neurosciences, Community Health Sciences, and Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Departments of Clinical Neurosciences, Community Health Sciences, and Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Aravind Ganesh
- Calgary Stroke Program, Departments of Clinical Neurosciences, Community Health Sciences, and Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada .,Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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15
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McDonough RV, Ospel JM, Majoie CBLM, Saver JL, White P, Dippel DWJ, Brown SB, Demchuk AM, Jovin TG, Mitchell PJ, Bracard S, Campbell BCV, Muir KW, Hill MD, Guillemin F, Goyal M. Clinical outcome of patients with mild pre-stroke morbidity following endovascular treatment: a HERMES substudy. J Neurointerv Surg 2023; 15:214-220. [PMID: 35210331 DOI: 10.1136/neurintsurg-2021-018428] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/20/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Analyses of the effect of pre-stroke functional levels on the outcome of endovascular therapy (EVT) have focused on the course of patients with moderate to substantial pre-stroke disability. The effect of complete freedom from pre-existing disability (modified Rankin Scale (mRS) 0) versus predominantly mild pre-existing disability/symptoms (mRS 1-2) has not been well delineated. METHODS The HERMES meta-analysis pooled data from seven randomized trials that tested the efficacy of EVT. We tested for a multiplicative interaction effect of pre-stroke mRS on the relationship between treatment and outcomes. Ordinal regression was used to assess the association between EVT and 90-day mRS (primary outcome) in the subgroup of patients with pre-stroke mRS 1-2. Multivariable regression modeling was then used to test the effect of mild pre-stroke disability/symptoms on the primary and secondary outcomes (delta-mRS, mRS 0-2/5-6) compared with patients with pre-stroke mRS 0. RESULTS We included 1764 patients, of whom 199 (11.3%) had pre-stroke mRS 1-2. No interaction effect of pre-stroke mRS on the relationship between treatment and outcome was observed. Patients with pre-stroke mRS 1-2 had worse outcomes than those with pre-stroke mRS 0 (adjusted common OR (acOR) 0.53, 95% CI 0.40 to 0.70). Nonetheless, a significant benefit of EVT was observed within the mRS 1-2 subgroup (cOR 2.08, 95% CI 1.22 to 3.55). CONCLUSIONS Patients asymptomatic/without disability prior to onset have better outcomes following EVT than patients with mild disability/symptoms. Patients with pre-stroke mRS 1-2, however, more often achieve good outcomes with EVT compared with conservative management. These findings indicate that mild pre-existing disability/symptoms influence patient prognosis after EVT but do not diminish the EVT treatment effect.
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Affiliation(s)
- Rosalie V McDonough
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany.,Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Johanna M Ospel
- Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeffrey L Saver
- Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | | | - Scott B Brown
- BRIGHT Research Partners, Mooresville, North Carolina, USA
| | - Andrew M Demchuk
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Peter J Mitchell
- Radiology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Serge Bracard
- Neuroradiology, Université de Lorraine, Nancy, France
| | - Bruce C V Campbell
- Medicine, University of Melbourne, Parkville, Victoria, Australia.,Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Keith W Muir
- Institute of Neuroscience and Psychology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Michael D Hill
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Francis Guillemin
- Department of Clinical Epidemiology, University Hospital Centre Nancy, Nancy, France
| | - Mayank Goyal
- Radiology, University of Calgary, Calgary, Alberta, Canada
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Nozoe M, Inoue T, Ishida M, Yamamoto K, Kanai M. Malnutrition on admission is associated with trunk function recovery but not with lower limb muscle strength recovery in patients with acute stroke: an observational cohort study. Nutrition 2023; 109:111971. [PMID: 36745968 DOI: 10.1016/j.nut.2023.111971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/26/2022] [Accepted: 01/01/2023] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The aim of this study was to determine the effects of malnutrition on trunk function and lower leg muscle strength in patients with acute stroke upon hospitalization. METHODS This prospective cohort study included hospitalized patients with acute stroke. Nutritional status was assessed using the Global Leadership Initiative on Malnutrition criteria. Trunk function and lower leg muscle strength were assessed using the trunk control test (TCT) and Motricity Index (MI), respectively, on admission and at discharge. Logistic regression analysis was performed to examine the relationship between malnutrition and poor improvement in TCT and MI scores at discharge. RESULTS Patients (N = 241) with acute stroke (median age 79 y) were included in this study. In adjusted logistic regression analysis, malnutrition was independently associated with poor TCT score improvement (adjusted odds ratio, 3.82; 95% confidence interval, 1.11-13.20; P = 0.03). In contrast, malnutrition was not independently associated with poor MI score improvement (adjusted odds ratio, 0.86; 95% confidence interval, 0.30-2.52; P = 0.79). CONCLUSION Malnutrition on admission leads to poor trunk function, but not lower leg muscle strength, in patients with acute stroke.
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Affiliation(s)
- Masafumi Nozoe
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women's University, Kobe, Japan.
| | - Tatsuro Inoue
- Department of Physical Therapy, Niigata University of Health and Welfare, Niigata, Japan
| | - Mitsuru Ishida
- Department of Rehabilitation, Konan Medical Center, Kobe, Japan
| | - Kenta Yamamoto
- Department of Rehabilitation, Konan Medical Center, Kobe, Japan
| | - Masashi Kanai
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women's University, Kobe, Japan
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17
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Ospel JM, Kunz WG, McDonough RV, van Zwam W, Pinckaers F, Saver JL, Hill MD, Demchuk AM, Jovin TG, Mitchell P, Campbell BCV, White P, Muir K, Achit H, Bracard S, Brown S, Goyal M. Cost-Effectiveness of Endovascular Treatment in Large Vessel Occlusion Stroke With Mild Prestroke Disability: Results From the HERMES Collaboration. Stroke 2023; 54:226-233. [PMID: 36472199 DOI: 10.1161/strokeaha.121.038407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical and economic benefit of endovascular treatment (EVT) in addition to best medical management in patients with stroke with mild preexisting symptoms/disability is not well studied. We aimed to investigate cost-effectiveness of EVT in patients with large vessel occlusion and mild prestroke symptoms/disability, defined as a modified Rankin Scale score of 1 or 2. METHODS Data are from the HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials), which pooled patient-level data from 7 large, randomized EVT trials. We used a decision model consisting of a short-run model to analyze costs and functional outcomes within 90 days after the index stroke and a long-run Markov state transition model (cycle length of 12 months) to estimate expected lifetime costs and outcomes from a health care and a societal perspective. Incremental cost-effectiveness ratio and net monetary benefits were calculated, and a probabilistic sensitivity analysis was performed. RESULTS EVT in addition to best medical management resulted in lifetime cost savings of $2821 (health care perspective) or $5378 (societal perspective) and an increment of 1.27 quality-adjusted life years compared with best medical management alone, indicating dominance of additional EVT as a treatment strategy. The net monetary benefits were higher for EVT in addition to best medical management compared with best medical management alone both at the higher (100 000$/quality-adjusted life years) and lower (50 000$/quality-adjusted life years) willingness to pay thresholds. Probabilistic sensitivity analysis showed decreased costs and an increase in quality-adjusted life years for additional EVT compared with best medical management only. CONCLUSIONS From a health-economic standpoint, EVT in addition to best medical management should be the preferred strategy in patients with acute ischemic stroke with large vessel occlusion and mild prestroke symptoms/disability.
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Affiliation(s)
- Johanna M Ospel
- Department of Neuroradiology, University Hospital Basel, Switzerland (J.M.O.).,Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
| | - Rosalie V McDonough
- Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
| | - Wim van Zwam
- Department of Radiology, Maastricht University Medical Center, the Netherlands (W.v.Z.)
| | | | - Jeffrey L Saver
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Michael D Hill
- Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
| | - Tudor G Jovin
- Department of Neurology, Cooper University Health Care, Camden (T.G.J.)
| | - Peter Mitchell
- Department of Radiology (P.M.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Bruce C V Campbell
- Department of Neurology (B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Phil White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | - Keith Muir
- Department of Neurology, University of Glasgow, Scotland (K.M.)
| | - Hamza Achit
- Department of Medicine (H.A.), Nancy University Hospital, France
| | - Serge Bracard
- Department of Neuroradiology (S.B.), Nancy University Hospital, France
| | - Scott Brown
- Altair Biostatistics, St Louis Park' MN (S.B.)
| | - Mayank Goyal
- Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
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18
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Yang JC, Bao QJ, Guo Y, Chen SJ, Zhang JT, Zhang Q, Zhou P, Yang MF. Endovascular thrombectomy in acute ischemic stroke patients with prestroke disability (mRS ≥2): A systematic review and meta-analysis. Front Neurol 2022; 13:971399. [PMID: 36188370 PMCID: PMC9520304 DOI: 10.3389/fneur.2022.971399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/19/2022] [Indexed: 11/29/2022] Open
Abstract
Objective The effect of endovascular thrombectomy (EVT) in acute ischemic stroke patients with prestroke disability (modified Rankin Scale score, mRS) ≥2) has not been well-studied. This study aimed to assess the safety and benefit of EVT in patients with prestroke disability. Methods According to PRISMA guidelines, literature searching was performed using PubMed, Embase, and Cochrane databases, for a series of acute ischemic stroke patients with prestroke mRS ≥2 treated by EVT. Random-effects meta-analysis was used to pool the rate of return to prestroke mRS and mortality at 3-month follow-up. Results In total, 13 observational studies, with 2,625 patients, were analyzed. The rates of return to prestroke mRS in patients with prestroke mRS of 2–4 were 20% (120/588), 27% (218/827), and 31% (34/108), respectively. Patients with prestroke disability treated by EVT had a higher likelihood of return to prestroke mRS (relative risk, RR, 1.86; 95% CI 1.28–2.70) and a lower likelihood of mortality (RR 0.75; 95%CI 0.58–0.97) compared with patients with standard medical treatment. Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b-3) after EVT gave a higher likelihood of return to prestroke mRS (RR 2.04; 95% CI 1.17–3.55) and lower mortality (RR 0.72; 95% CI 0.62–0.84) compared with unsuccessful reperfusion. Conclusions Acute ischemic stroke patients with prestroke disability may benefit from EVT. Withholding EVT on the sole ground of prestroke disabilities may not be justified. Systematic Review Registration:https://www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Jin-Cai Yang
- Graduate School, Qinghai University, Xining, China
| | - Qiang-Ji Bao
- Graduate School, Qinghai University, Xining, China
| | - Yu Guo
- Graduate School, Qinghai University, Xining, China
| | - Shu-Jun Chen
- Graduate School, Qinghai University, Xining, China
| | | | - Qiang Zhang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, China
| | - Ping Zhou
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, China
| | - Ming-Fei Yang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, China
- *Correspondence: Ming-Fei Yang
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19
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Ganesh A, Fladt J, Singh N, Goyal M. Efficacy and safety of mechanical thrombectomy in acute stroke patients with pre-morbid disability. Expert Rev Med Devices 2022; 19:641-648. [PMID: 36093630 DOI: 10.1080/17434440.2022.2124109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION – Patients with pre-morbid disability have been generally excluded from randomized controlled trials of mechanical thrombectomy for acute ischemic stroke. However, stroke physicians commonly encounter such patients in practice, and face challenging treatment decisions when caring for them. AREAS COVERED – We review the literature on the safety and efficacy of thrombectomy in patients with pre-morbid disability. Recent clinical-epidemiological studies have highlighted the adverse outcomes that come with each increment of additional post-stroke disability in these patients. Several observational studies - both case series and registry-based studies - have helped demonstrate the comparable safety of thrombectomy in patients with pre-morbid disability as in those without, complementing similar data on thrombolysis. These data also suggest similar rates of successful recanalization, symptomatic intracerebral hemorrhage, and return to pre-stroke level of disability when treated with mechanical thrombectomy, although they have higher mortality. EXPERT OPINION – In the absence of high-quality evidence, we recommend pursuing shared decision-making with patients or family members and being upfront about the uncertain evidence. Available observational data underline the potential for a substantial proportion of these patients to return to their pre-morbid state, do not indicate a greater rate of treatment-related complications, and do not support routinely excluding these patients from thrombectomy.
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Affiliation(s)
- Aravind Ganesh
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Hotchkiss Brain Institute and the Mathison Centre for Mental Health Research and Education, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Joachim Fladt
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nishita Singh
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Hotchkiss Brain Institute and the Mathison Centre for Mental Health Research and Education, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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20
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Nozoe M, Noguchi M, Kubo H, Kanai M, Shimada S. Association between the coexistence of premorbid sarcopenia, frailty, and disability and functional outcome in older patients with acute stroke. Geriatr Gerontol Int 2022; 22:642-647. [PMID: 35848637 DOI: 10.1111/ggi.14432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/26/2022] [Accepted: 06/14/2022] [Indexed: 11/29/2022]
Abstract
AIM To investigate the effects of coexisting conditions such as premorbid sarcopenia, frailty, and disability on functional outcomes in older patients with acute stroke. METHODS This prospective cohort study included older patients (aged ≥65 years) hospitalized for acute stroke at a single neurosurgical hospital. Premorbid sarcopenia, frailty, and disability were diagnosed using the strength, assistance with walking, rising from a chair, climbing stairs, and falls (SARC-F) questionnaire, frailty index, and modified Rankin Scale (mRS) on admission. The primary outcome was the mRS score 3 months after stroke, and a poor outcome was defined as mRS ≥4. RESULTS This study included 317 older patients with acute stroke (median [interquartile range] age: 76 [12] years). Premorbid sarcopenia, frailty, and disability (mRS = 2 or 3) were identified in 59 (19%), 27 (9%), and 54 (17%) patients, respectively. Two coexisting conditions were observed in 26 patients (8%), and three were observed in 18 patients (6%). Adjusted logistic regression analysis revealed that coexisting conditions were independently associated with poor outcomes (one condition, adjusted OR: 3.20 [95%CI: 0.98-10.45]; two conditions, adjusted OR: 6.57 [95%CI: 1.74-24.87]; three conditions, adjusted OR: 12.70 [95%CI: 2.65-60.91]). CONCLUSIONS The coexistence of premorbid sarcopenia, frailty, and disability was associated with poor functional outcomes in older patients with acute stroke. Geriatr Gerontol Int 2022; ••: ••-••.
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Affiliation(s)
- Masafumi Nozoe
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women's University, Kobe, Japan
| | - Madoka Noguchi
- Department of Rehabilitation, Itami Kousei Neurosurgical Hospital, Itami, Japan
| | - Hiroki Kubo
- Department of Rehabilitation, Itami Kousei Neurosurgical Hospital, Itami, Japan
| | - Masashi Kanai
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women's University, Kobe, Japan
| | - Shinichi Shimada
- Department of Neurosurgery, Itami Kousei Neurosurgical Hospital, Itami, Japan
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21
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Beland B, Bala F, Ganesh A. Thrombolysis for Acute Ischemic Stroke in Patients With Premorbid Disability: A Meta-Analysis. Stroke 2022; 53:3055-3063. [PMID: 35686556 DOI: 10.1161/strokeaha.121.038374] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Randomized controlled trials for the use of alteplase in acute ischemic stroke have excluded or had little representation of patients with prestroke disability, and the benefit of alteplase in this population remains uncertain. We performed a systematic review and meta-analysis to examine the outcomes of thrombolysis in patients with premorbid disability. METHODS We performed a systematic review in accordance with the Meta-Analysis of Observational Studies in Epidemiology guidelines and retrieved studies reporting intravenous thrombolysis (IVT) in patients with prestroke disability (modified Rankin Scale score, 3-5) with acute ischemic stroke, either compared with untreated patients or treated patients without premorbid disability. The primary outcome was the return to premorbid disability at 90 days. Secondary outcomes included rate and odds ratio of favorable functional outcome at 90 days (modified Rankin Scale score 0-2 or return to premorbid modified Rankin Scale), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. RESULTS Eight articles were included involving 103 988 patients. Patients with disability treated with IVT had better odds of returning to baseline function compared with those who did not receive IVT (odds ratio, 7.26 [95% CI, 2.51-21.02]). Mortality and rates of sICH were not significantly different between patients with disability treated with IVT and those not treated, although there were numerically more sICHs in the IVT group. Return to baseline function was not significantly different between patients with and without prestroke disability (odds ratio, 1.46 [95% CI, 0.75-2.83]). The rates of sICH were not significantly different in patients with and without premorbid disability. However, mortality was 3× higher in patients with premorbid disability than in those without premorbid disability (38.2% versus 12.6%). CONCLUSIONS The use of IVT in patients with disability was associated with better outcomes compared with patients who did not receive IVT without statistically significant added risks of sICH or mortality. When compared with those without disability, there was no significant difference in the return to baseline function or sICH. High-quality data comparing treated versus untreated patients with premorbid disability are needed to clarify this issue. REGISTRATION URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021240499.
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Affiliation(s)
- Benjamin Beland
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Fouzi Bala
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
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22
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Denny MC, Gattellari M. Different Strokes for Different Folks: Socioeconomic Disadvantage and Access to Stroke Reperfusion Therapies. Stroke 2022; 53:2317-2319. [PMID: 35579015 DOI: 10.1161/strokeaha.122.039353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- M Carter Denny
- Department of Neurology, Georgetown University Medical Center and MedStar Health, Washington, DC (M.C.D.)
| | - Melina Gattellari
- Department of Neurology, The Royal Prince Alfred Hospital, Camperdown, Sydney, Australia (M.G.)
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23
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Ganesh A, Fraser JF, Gordon Perue GL, Amin-Hanjani S, Leslie-Mazwi TM, Greenberg SM, Couillard P, Asdaghi N, Goyal M. Endovascular Treatment and Thrombolysis for Acute Ischemic Stroke in Patients With Premorbid Disability or Dementia: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2022; 53:e204-e217. [PMID: 35343235 DOI: 10.1161/str.0000000000000406] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Patients with premorbid disability or dementia have generally been excluded from randomized controlled trials of reperfusion therapies such as thrombolysis and endovascular therapy for acute ischemic stroke. Consequently, stroke physicians face treatment dilemmas in caring for such patients. In this scientific statement, we review the literature on acute ischemic stroke in patients with premorbid disability or dementia and propose principles to guide clinicians, clinician-scientists, and policymakers on the use of acute stroke therapies in these populations. Recent clinical-epidemiological studies have demonstrated challenges in our concept and measurement of premorbid disability or dementia while highlighting the significant proportion of the general stroke population that falls under this umbrella, risking exclusion from therapies. Such studies have also helped clarify the adverse long-term clinical and health economic consequences with each increment of additional poststroke disability in these patients, underscoring the importance of finding strategies to mitigate such additional disability. Several observational studies, both case series and registry-based studies, have helped demonstrate the comparable safety of endovascular therapy in patients with premorbid disability or dementia and in those without, complementing similar data on thrombolysis. These data also suggest that such patients have a substantial potential to retain their prestroke level of disability when treated, despite their generally worse prognosis overall, although this remains to be validated in higher-quality registries and clinical trials. By pairing pragmatic and transparent decision-making in clinical practice with an active pursuit of high-quality research, we can work toward a more inclusive paradigm of patient-centered care for this often-neglected patient population.
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24
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Haranhalli N, Fortunel A, Javed K, Zampolin R, Brook A, Liberman A, Lee SK, Altschul D, Schechter C. Cost-effective analysis of mechanical thrombectomy (MT) in patients with poor baseline modified Rankin Score (mRS). J Clin Neurosci 2022; 99:94-98. [PMID: 35278935 DOI: 10.1016/j.jocn.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 02/11/2022] [Accepted: 03/02/2022] [Indexed: 11/25/2022]
Abstract
Mechanical thrombectomy (MT) has been established as a standard of care for patients with acute ischemic stroke for the past five years. However, the direct benefits of this treatment in patients with baseline disability remains unclear. This study aims to elucidate the cost impact of performing MT on patients with moderate-to-severe baseline disability to work towards an optimized system of care for acute ischemic stroke. We developed a Markov economic model with a life-time horizon analysis of costs associated with mechanical thrombectomy in patients grouped on baseline disability as defined by modified Rankin Score. Our clinical and economic data is based on an American payer perspective. Our results identified a marginal cost-effective ratio (mCER) of $18,835.00 per quality-adjusted life year (QALY) when mechanical thrombectomy is reserved as a treatment only for patients with no-to-minimal baseline disability as compared to those with any level of baseline disability. Our results provide a framework for these future studies and highlight key sectors that drive cost in the surgical treatment and life-long care of patients with acute ischemic stroke.
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Affiliation(s)
- Neil Haranhalli
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, USA.
| | - Adisson Fortunel
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, USA
| | - Kainaat Javed
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, USA
| | - Richard Zampolin
- Department of Radiology, Montefiore Medical Center, Bronx, NY, USA
| | - Allan Brook
- Department of Radiology, Montefiore Medical Center, Bronx, NY, USA
| | - Ava Liberman
- Department of Neurology, Montefiore Medical Center, Bronx, NY, USA
| | - Seon-Kyu Lee
- Department of Radiology, Montefiore Medical Center, Bronx, NY, USA
| | - David Altschul
- Department of Radiology, Montefiore Medical Center, Bronx, NY, USA
| | - Clyde Schechter
- Departments of Family and Social Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
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25
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Kjörk EK, Gustavsson M, El-Manzalawy N, Sunnerhagen KS. Stroke-related health problems and associated actions identified with the post-stroke checklist among nursing home residents. BMC Cardiovasc Disord 2022; 22:50. [PMID: 35164696 PMCID: PMC8842537 DOI: 10.1186/s12872-022-02466-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 01/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background Little is known about the needs of permanent nursing home residents after a stroke; comprehensive descriptions of needs are rare. The Post-Stroke Checklist facilitates the identification of health problems. The study aimed to use the Post-Stroke Checklist to identify the extent of health problems, and how they were addressed, in nursing home residents that experienced strokes in Sweden. We also investigated the feasibility of the Checklist in a nursing home context. Methods This is a cross-sectional explorative study. Twenty nursing homes in two regions of Sweden participated. We included residents that had experienced a stroke within approximately 3 years and the responsible staff members were approached. Questionnaires were completed during face-to-face meetings with staff members (n = 45) knowledgeable about the residents. Data collection included the Post-Stroke Checklist, Barthel Index, modified Rankin Scale, resident and staff characteristics, and a satisfaction-questionnaire completed by staff. Results At the included nursing homes 1061 residents, 22% (n = 239) had a history of stroke, and 6% (n = 65) had experienced strokes during the last 3.5 years. Forty-nine residents were included (41% men, median age, 86 years, range 59–97). Among the health problems identified with the Checklist, activities of daily living (82%) were most common, and spasticity (41%) and pain (29%) were least common. Residents had extensive care needs, with a median of six health problems per resident. The total number of health problems addressed by previous actions i.e., referrals, as suggested in the Checklist, was 124, when recalled by staff. The median Barthel index score was 35. Lack of follow-up after stroke (e.g., by using a checklist) was reported in 17/20 nursing homes. The staff were satisfied with the Post-Stroke Checklist. Conclusions We found that more than 1/5 of residents had experienced a stroke; thus, the Post-Stroke Checklist was a useful tool in nursing homes. Half of the residents had more than six health problems, identified with the Post-Stroke Checklist. Extensive needs, combined with a lack of follow-up, indicated a risk of insufficient care. These findings suggested that nursing home routines could be improved with the Post-Stroke Checklist. Trial registration The project is registered in Research web, project number: 256021.
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Affiliation(s)
- Emma K Kjörk
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy at University of Gothenburg, Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden.
| | - Martha Gustavsson
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy at University of Gothenburg, Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden
| | - Nohad El-Manzalawy
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy at University of Gothenburg, Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden
| | - Katharina S Sunnerhagen
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy at University of Gothenburg, Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden
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26
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Inoue S, Mori N, Tsujikawa M, Ishii R, Suzuki K, Kondo K, Kawakami M. Determinants of Step-through Gait Pattern Acquisition in Subacute Stroke Patients. Prog Rehabil Med 2022; 7:20220035. [PMID: 35935454 PMCID: PMC9293622 DOI: 10.2490/prm.20220035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/28/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Seigo Inoue
- Department of Rehabilitation Medicine, Tokyo Bay Rehabilitation Hospital, Tokyo, Japan
| | - Naoki Mori
- Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Tsujikawa
- Department of Rehabilitation Medicine, Tokyo Bay Rehabilitation Hospital, Tokyo, Japan
| | - Ryota Ishii
- Department of Biostatistics, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kanjiro Suzuki
- Department of Rehabilitation Medicine, Tokyo Bay Rehabilitation Hospital, Tokyo, Japan
| | - Kunitsugu Kondo
- Department of Rehabilitation Medicine, Tokyo Bay Rehabilitation Hospital, Tokyo, Japan
| | - Michiyuki Kawakami
- Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
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27
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Gil-Salcedo A, Dugravot A, Fayosse A, Landré B, Jacob L, Bloomberg M, Sabia S, Schnitzler A. Pre-stroke Disability and Long-Term Functional Limitations in Stroke Survivors: Findings From More of 12 Years of Follow-Up Across Three International Surveys of Aging. Front Neurol 2022; 13:888119. [PMID: 35775052 PMCID: PMC9237334 DOI: 10.3389/fneur.2022.888119] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background Almost 50% of the post-stroke disabled population already have a premorbid disability before stroke. These patients may be offered a different care pathway in the acute and subacute phase than those without pre-morbid disability. Therefore, the aim of this study was to assess the association of the severity of premorbid disability with change of limitations in basic and instrumental activities of daily living (ADL/IADL) 1 year after stroke and over the following decade. Methods Among 3,432 participants from HRS, SHARE and ELSA cohorts with a first stroke, ADL/IADL limitations were measured at 1-2 years prior to stroke, at 1 year post-stroke, and during the chronic phase. Modified Ranking Scale (P-mRS) was used to categorize the participants by level of premorbid disability (1-2 years pre-stroke). Change in ADL/IADL limitations by P-mRS level (0-1, 2-3, and 4-5) was assessed using a piecewise linear mixed model with a breakpoint set at 1 year post-stroke, stratified by median age groups. Results Increase in ADL limitations at 1 year post-stroke was less pronounced in P-mRS ≥2 (p < 0.005). After years of relative stability, limitations of ADL increased for all P-mRS levels (p = 0.003). In those aged ≥75 years at stroke event, the increase was similar irrespective of P-mRS (p = 0.090). There were no significant differences in IADL trajectories between P-mRS levels (p ≥ 0.127). Conclusion These results suggest similar trajectories of functional limitations between P-mRS levels up to 9 years post-stroke, highlighting the possible benefit of including patients with pre-morbid disability to certain treatments during the acute phase.
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Affiliation(s)
- Andres Gil-Salcedo
- Université Paris-Cité, Inserm U1153, Epidemiology of Ageing and Neurodegenerative Diseases, Paris, France
| | - Aline Dugravot
- Université Paris-Cité, Inserm U1153, Epidemiology of Ageing and Neurodegenerative Diseases, Paris, France
| | - Aurore Fayosse
- Université Paris-Cité, Inserm U1153, Epidemiology of Ageing and Neurodegenerative Diseases, Paris, France
| | - Benjamin Landré
- Université Paris-Cité, Inserm U1153, Epidemiology of Ageing and Neurodegenerative Diseases, Paris, France
| | - Louis Jacob
- Faculty of Medicine, University of Versailles Saint-Quentin-en-Yvelines, Montigny-le-Bretonneux, France.,Research and Development Unit, Parc Sanitari Sant Joan de Déu, CIBERSAM, Barcelona, Spain
| | - Mikaela Bloomberg
- Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Séverine Sabia
- Université Paris-Cité, Inserm U1153, Epidemiology of Ageing and Neurodegenerative Diseases, Paris, France
| | - Alexis Schnitzler
- Université Paris-Cité, Inserm U1153, Epidemiology of Ageing and Neurodegenerative Diseases, Paris, France.,Université Versailles Saint Quentin en Yvelines, EA 4047 Handi-Resp, Service de neurologie hôpital A. Mignot, Garches, France
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Bulwa Z, Chen M. Stroke Center Designations, Neurointerventionalist Demand, and the Finances of Stroke Thrombectomy in the United States. Neurology 2021; 97:S17-S24. [PMID: 34785600 DOI: 10.1212/wnl.0000000000012780] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 11/24/2020] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Zachary Bulwa
- From the Departments of Neurology (Z.B.) and Neurosurgery (M.C.), Rush University Medical Center, Chicago, IL.
| | - Michael Chen
- From the Departments of Neurology (Z.B.) and Neurosurgery (M.C.), Rush University Medical Center, Chicago, IL
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de Havenon A, Castonguay A, Nogueira R, Nguyen TN, English J, Satti SR, Veznedaroglu E, Saver JL, Mocco J, Khatri P, Mistry E, Zaidat OO. Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke. Neurology 2021; 97:e1914-e1919. [PMID: 34544817 DOI: 10.1212/wnl.0000000000012827] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 08/27/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To determine the impact of endovascular therapy for large vessel occlusion stroke in patients with vs those without premorbid disability. METHODS We performed a post hoc analysis of the TREVO Stent-Retriever Acute Stroke (TRACK) Registry, which collected data on 634 consecutive patients with stroke treated with the Trevo device as first-line endovascular thrombectomy (EVT) at 23 centers in the United States. We included patients with internal carotid or middle cerebral (M1/M2 segment) artery occlusions, and the study exposure was patient- or caregiver-reported premorbid modified Rank Scale (mRS) score ≥2 (premorbid disability [PD]) vs premorbid mRS score of 0 to 1 (no PD [NPD]). The primary outcome was no accumulated disability, defined as no increase in 90-day mRS score from the patient's premorbid mRS score. RESULTS Of the 634 patients in TRACK, 407 patients were included in our cohort, of whom 53 (13.0%) had PD. The primary outcome of no accumulated disability was achieved in 37.7% (20 of 53) of patients with PD and 16.7% (59 of 354) of patients with NPD (p < 0.001), while death occurred in 39.6% (21 of 53) and 14.1% (50 of 354) (p < 0.001), respectively. The adjusted odds ratio of no accumulated disability for patients with PD was 5.2 (95% confidence interval [CI] 2.4-11.4, p < 0.001) compared to patients with NPD. However, the adjusted odds ratio for death in patients with PD was 2.90 (95% CI 1.38-6.09, p = 0.005). DISCUSSION In this study of patients with anterior circulation acute ischemic stroke treated with EVT, we found that PD was associated with a higher probability of not accumulating further disability compared to patients with NPD but also with higher probability of death. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that in anterior circulation acute ischemic stroke treated with EVT, patients with PD compared to those without disability were more likely not to accumulate more disability but were more likely to die.
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Affiliation(s)
- Adam de Havenon
- From the Department of Neurology (A.d.H.), University of Utah, Salt Lake City; Department of Neurology (A.C.), University of Toledo, OH; Department of Neurology, Neurosurgery, and Radiology (R.N.), Emory University, Atlanta, GA; Department of Neurology, Neurosurgery, and Radiology (T.N.N.), Boston Medical Center, MA; California Pacific Medical Center (J.E.), San Francisco; Department of Neurointerventional Surgery (S.R.S.), Christiana Care Health System, Newark, DE; Department of Neurosurgery (E.V.), Drexel Neurosciences Institute, Philadelphia, PA; Department of Neurology (J.L.S.), University of California, Los Angeles; Department of Neurosurgery (J.M.), Mt. Sinai, New York, NY; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Neurology (E.M.), Vanderbilt Medical Center, Nashville, TN; and Department of Neurology (O.O.Z.), Mercy Health-St. Vincent Medical Center, Toledo, OH.
| | - Alicia Castonguay
- From the Department of Neurology (A.d.H.), University of Utah, Salt Lake City; Department of Neurology (A.C.), University of Toledo, OH; Department of Neurology, Neurosurgery, and Radiology (R.N.), Emory University, Atlanta, GA; Department of Neurology, Neurosurgery, and Radiology (T.N.N.), Boston Medical Center, MA; California Pacific Medical Center (J.E.), San Francisco; Department of Neurointerventional Surgery (S.R.S.), Christiana Care Health System, Newark, DE; Department of Neurosurgery (E.V.), Drexel Neurosciences Institute, Philadelphia, PA; Department of Neurology (J.L.S.), University of California, Los Angeles; Department of Neurosurgery (J.M.), Mt. Sinai, New York, NY; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Neurology (E.M.), Vanderbilt Medical Center, Nashville, TN; and Department of Neurology (O.O.Z.), Mercy Health-St. Vincent Medical Center, Toledo, OH
| | - Raul Nogueira
- From the Department of Neurology (A.d.H.), University of Utah, Salt Lake City; Department of Neurology (A.C.), University of Toledo, OH; Department of Neurology, Neurosurgery, and Radiology (R.N.), Emory University, Atlanta, GA; Department of Neurology, Neurosurgery, and Radiology (T.N.N.), Boston Medical Center, MA; California Pacific Medical Center (J.E.), San Francisco; Department of Neurointerventional Surgery (S.R.S.), Christiana Care Health System, Newark, DE; Department of Neurosurgery (E.V.), Drexel Neurosciences Institute, Philadelphia, PA; Department of Neurology (J.L.S.), University of California, Los Angeles; Department of Neurosurgery (J.M.), Mt. Sinai, New York, NY; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Neurology (E.M.), Vanderbilt Medical Center, Nashville, TN; and Department of Neurology (O.O.Z.), Mercy Health-St. Vincent Medical Center, Toledo, OH
| | - Thanh N Nguyen
- From the Department of Neurology (A.d.H.), University of Utah, Salt Lake City; Department of Neurology (A.C.), University of Toledo, OH; Department of Neurology, Neurosurgery, and Radiology (R.N.), Emory University, Atlanta, GA; Department of Neurology, Neurosurgery, and Radiology (T.N.N.), Boston Medical Center, MA; California Pacific Medical Center (J.E.), San Francisco; Department of Neurointerventional Surgery (S.R.S.), Christiana Care Health System, Newark, DE; Department of Neurosurgery (E.V.), Drexel Neurosciences Institute, Philadelphia, PA; Department of Neurology (J.L.S.), University of California, Los Angeles; Department of Neurosurgery (J.M.), Mt. Sinai, New York, NY; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Neurology (E.M.), Vanderbilt Medical Center, Nashville, TN; and Department of Neurology (O.O.Z.), Mercy Health-St. Vincent Medical Center, Toledo, OH
| | - Joey English
- From the Department of Neurology (A.d.H.), University of Utah, Salt Lake City; Department of Neurology (A.C.), University of Toledo, OH; Department of Neurology, Neurosurgery, and Radiology (R.N.), Emory University, Atlanta, GA; Department of Neurology, Neurosurgery, and Radiology (T.N.N.), Boston Medical Center, MA; California Pacific Medical Center (J.E.), San Francisco; Department of Neurointerventional Surgery (S.R.S.), Christiana Care Health System, Newark, DE; Department of Neurosurgery (E.V.), Drexel Neurosciences Institute, Philadelphia, PA; Department of Neurology (J.L.S.), University of California, Los Angeles; Department of Neurosurgery (J.M.), Mt. Sinai, New York, NY; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Neurology (E.M.), Vanderbilt Medical Center, Nashville, TN; and Department of Neurology (O.O.Z.), Mercy Health-St. Vincent Medical Center, Toledo, OH
| | - Sudhakar Reddy Satti
- From the Department of Neurology (A.d.H.), University of Utah, Salt Lake City; Department of Neurology (A.C.), University of Toledo, OH; Department of Neurology, Neurosurgery, and Radiology (R.N.), Emory University, Atlanta, GA; Department of Neurology, Neurosurgery, and Radiology (T.N.N.), Boston Medical Center, MA; California Pacific Medical Center (J.E.), San Francisco; Department of Neurointerventional Surgery (S.R.S.), Christiana Care Health System, Newark, DE; Department of Neurosurgery (E.V.), Drexel Neurosciences Institute, Philadelphia, PA; Department of Neurology (J.L.S.), University of California, Los Angeles; Department of Neurosurgery (J.M.), Mt. Sinai, New York, NY; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Neurology (E.M.), Vanderbilt Medical Center, Nashville, TN; and Department of Neurology (O.O.Z.), Mercy Health-St. Vincent Medical Center, Toledo, OH
| | - Erol Veznedaroglu
- From the Department of Neurology (A.d.H.), University of Utah, Salt Lake City; Department of Neurology (A.C.), University of Toledo, OH; Department of Neurology, Neurosurgery, and Radiology (R.N.), Emory University, Atlanta, GA; Department of Neurology, Neurosurgery, and Radiology (T.N.N.), Boston Medical Center, MA; California Pacific Medical Center (J.E.), San Francisco; Department of Neurointerventional Surgery (S.R.S.), Christiana Care Health System, Newark, DE; Department of Neurosurgery (E.V.), Drexel Neurosciences Institute, Philadelphia, PA; Department of Neurology (J.L.S.), University of California, Los Angeles; Department of Neurosurgery (J.M.), Mt. Sinai, New York, NY; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Neurology (E.M.), Vanderbilt Medical Center, Nashville, TN; and Department of Neurology (O.O.Z.), Mercy Health-St. Vincent Medical Center, Toledo, OH
| | - Jeffrey L Saver
- From the Department of Neurology (A.d.H.), University of Utah, Salt Lake City; Department of Neurology (A.C.), University of Toledo, OH; Department of Neurology, Neurosurgery, and Radiology (R.N.), Emory University, Atlanta, GA; Department of Neurology, Neurosurgery, and Radiology (T.N.N.), Boston Medical Center, MA; California Pacific Medical Center (J.E.), San Francisco; Department of Neurointerventional Surgery (S.R.S.), Christiana Care Health System, Newark, DE; Department of Neurosurgery (E.V.), Drexel Neurosciences Institute, Philadelphia, PA; Department of Neurology (J.L.S.), University of California, Los Angeles; Department of Neurosurgery (J.M.), Mt. Sinai, New York, NY; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Neurology (E.M.), Vanderbilt Medical Center, Nashville, TN; and Department of Neurology (O.O.Z.), Mercy Health-St. Vincent Medical Center, Toledo, OH
| | - J Mocco
- From the Department of Neurology (A.d.H.), University of Utah, Salt Lake City; Department of Neurology (A.C.), University of Toledo, OH; Department of Neurology, Neurosurgery, and Radiology (R.N.), Emory University, Atlanta, GA; Department of Neurology, Neurosurgery, and Radiology (T.N.N.), Boston Medical Center, MA; California Pacific Medical Center (J.E.), San Francisco; Department of Neurointerventional Surgery (S.R.S.), Christiana Care Health System, Newark, DE; Department of Neurosurgery (E.V.), Drexel Neurosciences Institute, Philadelphia, PA; Department of Neurology (J.L.S.), University of California, Los Angeles; Department of Neurosurgery (J.M.), Mt. Sinai, New York, NY; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Neurology (E.M.), Vanderbilt Medical Center, Nashville, TN; and Department of Neurology (O.O.Z.), Mercy Health-St. Vincent Medical Center, Toledo, OH
| | - Pooja Khatri
- From the Department of Neurology (A.d.H.), University of Utah, Salt Lake City; Department of Neurology (A.C.), University of Toledo, OH; Department of Neurology, Neurosurgery, and Radiology (R.N.), Emory University, Atlanta, GA; Department of Neurology, Neurosurgery, and Radiology (T.N.N.), Boston Medical Center, MA; California Pacific Medical Center (J.E.), San Francisco; Department of Neurointerventional Surgery (S.R.S.), Christiana Care Health System, Newark, DE; Department of Neurosurgery (E.V.), Drexel Neurosciences Institute, Philadelphia, PA; Department of Neurology (J.L.S.), University of California, Los Angeles; Department of Neurosurgery (J.M.), Mt. Sinai, New York, NY; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Neurology (E.M.), Vanderbilt Medical Center, Nashville, TN; and Department of Neurology (O.O.Z.), Mercy Health-St. Vincent Medical Center, Toledo, OH
| | - Eva Mistry
- From the Department of Neurology (A.d.H.), University of Utah, Salt Lake City; Department of Neurology (A.C.), University of Toledo, OH; Department of Neurology, Neurosurgery, and Radiology (R.N.), Emory University, Atlanta, GA; Department of Neurology, Neurosurgery, and Radiology (T.N.N.), Boston Medical Center, MA; California Pacific Medical Center (J.E.), San Francisco; Department of Neurointerventional Surgery (S.R.S.), Christiana Care Health System, Newark, DE; Department of Neurosurgery (E.V.), Drexel Neurosciences Institute, Philadelphia, PA; Department of Neurology (J.L.S.), University of California, Los Angeles; Department of Neurosurgery (J.M.), Mt. Sinai, New York, NY; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Neurology (E.M.), Vanderbilt Medical Center, Nashville, TN; and Department of Neurology (O.O.Z.), Mercy Health-St. Vincent Medical Center, Toledo, OH
| | - Osama O Zaidat
- From the Department of Neurology (A.d.H.), University of Utah, Salt Lake City; Department of Neurology (A.C.), University of Toledo, OH; Department of Neurology, Neurosurgery, and Radiology (R.N.), Emory University, Atlanta, GA; Department of Neurology, Neurosurgery, and Radiology (T.N.N.), Boston Medical Center, MA; California Pacific Medical Center (J.E.), San Francisco; Department of Neurointerventional Surgery (S.R.S.), Christiana Care Health System, Newark, DE; Department of Neurosurgery (E.V.), Drexel Neurosciences Institute, Philadelphia, PA; Department of Neurology (J.L.S.), University of California, Los Angeles; Department of Neurosurgery (J.M.), Mt. Sinai, New York, NY; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Neurology (E.M.), Vanderbilt Medical Center, Nashville, TN; and Department of Neurology (O.O.Z.), Mercy Health-St. Vincent Medical Center, Toledo, OH
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Rosa JL, Alves M, Ferreira P, Papoila AL, Nunes AP. Previous Disability and Benefit of Acute Phase Therapy in Functional Prognosis of Selected Patients with Ischemic Stroke. J Stroke Cerebrovasc Dis 2021; 31:106183. [PMID: 34717228 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/15/2021] [Accepted: 10/17/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Patients' previous disability (PD) is a key factor when considering acute stroke therapy. PD's exact impact on functional prognosis of patients with acute ischemic stroke remains not entirely clarified. We aimed to analyze PD's influence on functional outcome three months after ischemic stroke. MATERIALS AND METHODS Retrospective analysis of prospectively collected data concerning patients with acute ischemic stroke admitted to Stroke Unit of a tertiary center who underwent acute phase therapy between 2017 and 2019. Modified Rankin Scale (mRS) was used to define PD (with previous mRS≥3). Patients with PD were selected for treatment based on similar baseline characteristics to patients without PD. Patients were classified into two groups according to previous mRS: mRS<3 and mRS≥3. We defined bad outcome at three months after stroke as mRS≥3 for patients with previous mRS<3, and as a higher score than baseline mRS for patients with previous mRS≥3. RESULTS We identified 1169 eligible patients - 1016 patients with previous mRS<3 and 153 patients with previous mRS≥3. Most baseline characteristics did not differ significantly between them. For patients ≤75 years old, PD was associated with worse outcome (odds ratio estimate [OR] 4.50, p < 0.001). For patients >75 years old, PD was protective against worse outcome (OR 0.42, p < 0.001). In patients with previous mRS≥3 and >75 years old, there was a higher proportion of women (p = 0.005). CONCLUSIONS PD might not be a relevant factor when considering acute stroke therapy in selected patients >75 years old, especially women. Further studies are needed to clarify these findings.
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Affiliation(s)
- José Lourenço Rosa
- Neurology Department, Centro Hospitalar Universitário de Lisboa Central, Alameda Santo António dos Capuchos, Lisbon 1169-050, Portugal.
| | - Marta Alves
- Epidemiology and Statistics Unit, Research Center, Centro Hospitalar Universitário de Lisboa Central, NOVA Medical School/Faculdade de Ciências Médicas, Center of Statistics and its Applications, University of Lisbon, Lisbon, Portugal
| | - Patrícia Ferreira
- Stroke Unit, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Ana Luísa Papoila
- Epidemiology and Statistics Unit, Research Center, Centro Hospitalar Universitário de Lisboa Central, NOVA Medical School/Faculdade de Ciências Médicas, Center of Statistics and its Applications, University of Lisbon, Lisbon, Portugal
| | - Ana Paiva Nunes
- Stroke Unit, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
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31
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Salwi S, Niec JA, Hassan AE, Lindsell CJ, Khatri P, Mocco J, Saver JL, Mistry EA. Endovascular Treatment for Acute Stroke Patients With a Pre-stroke Disability: An International Survey. Front Neurol 2021; 12:714594. [PMID: 34671306 PMCID: PMC8520928 DOI: 10.3389/fneur.2021.714594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/31/2021] [Indexed: 11/21/2022] Open
Abstract
Background: It is unclear what factors clinicians consider when deciding about endovascular thrombectomy (EVT) in acute ischemic stroke patients with a pre-existing disability. We aimed to explore international practice patterns and preferences for EVT in patients with a pre-stroke disability, defined as a modified Rankin score (mRS) ≥ 2. Methods: Electronic survey link was sent to principal investigators of five major EVT trials and members of a professional interventional neurology society. Results: Of the 81 survey-responding clinicians, 57% were neuro-interventionalists and 33% were non-interventional stroke clinicians. Overall, 64.2% would never or almost never consider EVT for a patient with pre-stroke mRS of 4-5, and 49.3% would always or almost always offer EVT for a patient with pre-stroke mRS 2-3. Perceived benefit of EVT (89%) and severity of baseline disability (83.5%) were identified as the most important clinician-level and patient-level factors that influence EVT decisions in these patients. Conclusion: In this survey of 80 respondents, we found that EVT practice for patients with pre-stroke disability across the world is heterogenous and depends upon patient characteristics. Individual clinician opinions substantially alter EVT decisions in pre-stroke disabled patients.
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Affiliation(s)
- Sanjana Salwi
- School of Medicine, Vanderbilt University, Nashville, TN, United States
| | - Jan A Niec
- School of Medicine, Vanderbilt University, Nashville, TN, United States
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX, United States
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, United States
| | - Jeffrey L Saver
- Department of Neurology, University of Calfornia, Los Angeles, Los Angeles, CA, United States
| | - Eva A Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States
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Nozoe M, Kubo H, Kanai M, Yamamoto M. Relationships between Pre-Stroke SARC-F Scores, Disability, and Risk of Malnutrition and Functional Outcomes after Stroke-A Prospective Cohort Study. Nutrients 2021; 13:nu13103586. [PMID: 34684587 PMCID: PMC8537569 DOI: 10.3390/nu13103586] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/30/2021] [Accepted: 10/09/2021] [Indexed: 12/24/2022] Open
Abstract
SARC-F is a screening tool for sarcopenia; however, it has not yet been established whether SARC-F scores predict functional outcomes. Therefore, we herein investigated the relationship between SARC-F scores and functional outcomes in stroke patients. The primary outcome in the present study was the modified Rankin Scale (mRS) 3 months after stroke. The relationship between SARC-F scores and poor functional outcomes was examined using a logistic regression analysis. Furthermore, the applicability of SARC-F scores to the assessment of poor functional outcomes was analyzed based on the area under the receiver operating curve (ROC). Eighty-one out of the 324 patients enrolled in the present study (25%) had poor functional outcomes (mRS ≥ 4). The results of the multivariate analysis revealed a correlation between SARC-F scores (OR = 1.29, 95% CI = 1.05–1.59, p = 0.02) and poor functional outcomes. A cut-off SARC-F score ≥ 4 had low-to-moderate sensitivity (47.4%) and high specificity (87.3%). The present results suggest that the measurement of pre-stroke SARC-F scores is useful for predicting the outcomes of stroke patients.
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Affiliation(s)
- Masafumi Nozoe
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women’s University, Kobe 658-0001, Japan;
- Correspondence: ; Tel.: +81-78-413-3584
| | - Hiroki Kubo
- Department of Rehabilitation, Itami Kousei Neurosurgical Hospital, Itami 664-0028, Japan; (H.K.); (M.Y.)
| | - Masashi Kanai
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women’s University, Kobe 658-0001, Japan;
| | - Miho Yamamoto
- Department of Rehabilitation, Itami Kousei Neurosurgical Hospital, Itami 664-0028, Japan; (H.K.); (M.Y.)
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Ganesh A, Ospel JM, Marko M, van Zwam WH, Roos YBWEM, Majoie CBLM, Goyal M. From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke. Front Neurol 2021; 12:713738. [PMID: 34381418 PMCID: PMC8350336 DOI: 10.3389/fneur.2021.713738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond. Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT. Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability. Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.
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Affiliation(s)
- Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | | | - Martha Marko
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, Netherlands
| | | | | | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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Florent EG, Barbara C, Marc F, Maeva K, Fouzi B, Lucie DS, Charlotte C, Nicolas B, Hilde H. Clinical Outcomes and Safety of Mechanical Thrombectomy for Acute Ischaemic Stroke in Patients with Pre-Existing Dependency. J Stroke Cerebrovasc Dis 2021; 30:105848. [PMID: 33991770 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105848] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Pre-stroke dependency (PSD) is associated with poor outcome after stroke. The aim of the study was to evaluate the clinical outcomes and safety of mechanical thrombectomy (MT) in pre-stroke dependent patients compared to pre-stroke independent patients. MATERIAL AND METHODS We included consecutive patients with anterior circulation acute ischaemic stroke related to large vessel occlusion (AIS-LVO), treated by MT between January 1st 2015 and July 1st 2018 in our single comprehensive stroke center. PSD was defined as a mRS score of 3 to 5 before stroke onset. We studied outcome variables in pre-stroke dependent vs. independent patients, by using logistic regression models. Clinical outcomes included clinical favorable outcome at 3 months (defined as modified Rankin Score 0-2 or equal to pre-stroke mRS score), successful recanalization rates and safety outcomes. RESULTS Of 922 patients with anterior circulation AIS-LVO, 155 (16.8%) had PSD. Favorable outcome was less often achieved in patients with PSD (25.8% vs. 44.7%, p <0.001); but the difference did not remain significant in multivariable analysis (adjusted OR, 0.70; 95%CI, 0.44 to 1.12). Mortality at 90-days was significantly higher in patients with PSD (49.0% vs. 18.8%, adjusted OR, 2.63; 95%CI, 1.69 to 4.00). Successful recanalization was strongly associated with favorable outcome (adjusted OR, 8.15; 95%CI 4.97 to 13.34). CONCLUSIONS One out of four patients with PSD had a favorable outcome after MT. Despite higher mortality rates compared to pre-stroke independent patients, PSD alone should not be used alone to deny mechanical thrombectomy.
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Affiliation(s)
- El Grabli Florent
- Univ. Lille, Inserm U1172, CHU Lille, Department of Neurology, Stroke unit, France
| | - Casolla Barbara
- Univ. Lille, Inserm U1172, CHU Lille, Department of Neurology, Stroke unit, France.
| | - Ferrigno Marc
- Univ. Lille, Inserm U1172, CHU Lille, Department of Neurology, Stroke unit, France
| | - Kyheng Maeva
- Univ. Lille, CHU Lille, ULR 2694 - METRICS évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France.; CHU Lille, Département de Biostatistiques, F-59000 Lille, France
| | - Bala Fouzi
- Interventional Neuroradiology, CHU Lille, Lille, France
| | - Della Schiava Lucie
- Univ. Lille, Inserm U1172, CHU Lille, Department of Neurology, Stroke unit, France
| | - Cordonnier Charlotte
- Univ. Lille, Inserm U1172, CHU Lille, Department of Neurology, Stroke unit, France. https://twitter.com/PrCCordonnier
| | | | - Henon Hilde
- Univ. Lille, Inserm U1172, CHU Lille, Department of Neurology, Stroke unit, France
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Wang X, Moullaali TJ, Ouyang M, Billot L, Sandset EC, Song L, Delcourt C, Hackett ML, Watkins CL, Robinson TG, Yang J, Lavados PM, Brunser A, Olavarría VV, Muñoz-Venturelli P, Arima H, Middleton S, Pontes-Neto OM, Pandian JD, Rogers K, Anderson CS. Influence of Including Patients with Premorbid Disability in Acute Stroke Trials: The HeadPoST Experience. Cerebrovasc Dis 2021; 50:78-87. [PMID: 33434907 DOI: 10.1159/000512608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/26/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with premorbid functional impairment are generally excluded from acute stroke trials. We aimed to determine the impact of including such patients in the Head Positioning in acute Stroke Trial (HeadPoST) and early additional impairment on outcomes. METHODS Post hoc analyses of HeadPoST, an international, cluster-randomized crossover trial of lying-flat versus sitting-up head positioning in acute stroke. Associations of early additional impairment, defined as change in modified Rankin scale (mRS) scores from premorbid levels (estimated at baseline) to Day 7 ("early ΔmRS"), and poor outcome (mRS score 3-6) at Day 90 were determined with generalized linear mixed model. Heterogeneity of the trial treatment effect was tested according to premorbid mRS scores 0-1 versus 2-5. RESULTS Of 8,285 patients (38.9% female, mean age 68 ± 13 years) with complete data, there were 1,984 (23.9%) with premorbid functional impairment (mRS 2-5). A significant linear association was evident for early ∆mRS and poor outcome (per 1-point increase in ΔmRS, adjusted odds ratio 1.20, 95% confidence interval 1.14-1.27; p < 0.0001). Patients with greater premorbid functional impairment were less likely to develop additional impairment, but their risk of poor 90-day outcome significantly increased with increasing (worse) premorbid mRS scores (linear trend p < 0.0001). There was no heterogeneity of the trial treatment effect by level of premorbid function. CONCLUSIONS Early poststroke functional impairment that exceeded premorbid levels was associated with worse 90-day outcome, and this association increased with greater premorbid functional impairment. Yet, including premorbid impaired patients in the HeadPoST did not materially affect the subsequent treatment effect. CLINICAL TRIAL REGISTRATION HeadPoST is registered at http://www.ClinicalTrials.gov (NCT02162017).
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Affiliation(s)
- Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Camperdown, New South Wales, Australia.,Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Tom J Moullaali
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Camperdown, New South Wales, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Camperdown, New South Wales, Australia
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Lili Song
- The George Institute China at Peking University Health Science Center, Beijing, China
| | - Candice Delcourt
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Camperdown, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Maree L Hackett
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Camperdown, New South Wales, Australia.,Faculty of Health and Care, University of Central Lancashire, Preston, United Kingdom
| | - Caroline L Watkins
- Faculty of Health and Care, University of Central Lancashire, Preston, United Kingdom
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Jie Yang
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Pablo M Lavados
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurologíay Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | - Alejandro Brunser
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurologíay Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | - Verónica V Olavarría
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurologíay Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | - Paula Muñoz-Venturelli
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurologíay Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile.,Faculty of Health and Care, University of Central Lancashire, Preston, United Kingdom
| | - Hisatomi Arima
- Department of Public Health, Fukuoka University, Fukuoka, Japan
| | - Sandy Middleton
- Nursing Research Institute, Australian Catholic University and St Vincent's Health Network Sydney, Sydney, New South Wales, Australia
| | - Octávio M Pontes-Neto
- Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Ribeirão Preto, Brazil
| | | | - Kris Rogers
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Camperdown, New South Wales, Australia
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Camperdown, New South Wales, Australia, .,The Norwegian Air Ambulance Foundation, Oslo, Norway, .,Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia, .,Departamento de Ciencias Neurológicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile,
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Sennfält S, Pihlsgård M, Norrving B, Ullberg T, Petersson J. Ischemic stroke patients with prestroke dependency: Characteristics and long-term prognosis. Acta Neurol Scand 2021; 143:78-88. [PMID: 32738814 PMCID: PMC7754457 DOI: 10.1111/ane.13328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/29/2020] [Accepted: 07/26/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE This paper aims at examining the clinical characteristics of ischemic stroke patients with different levels of prestroke functional dependency, their long-term outcome, and determinants of five-year mortality. MATERIALS AND METHODS We describe demographics, comorbidity, treatment, as well as long-term mortality, and functional status of 5899 prestroke-dependent ischemic stroke patients stratified by dependency level and compared to a concurrent cohort of 14 148 prestroke-independent patients. The study was based on 2016 survey data from Riksstroke, the Swedish national stroke register, and patients were followed up at three months, 12 months, and either at three or five years. We used Cox regression for mortality predictor analysis and multiple imputation was performed to minimize bias from loss to follow-up. RESULTS With increasing level of prestroke dependency, comorbidity burden was higher, drug prescription lower, and prognosis less favorable. At three years, the proportion that had died or deteriorated were 82.6%, 87.5%, and 86.3% in moderate, moderately severe, and severe dependency, respectively. In moderate dependency, prognosis was relatively favorable: Three-month mortality was half of that seen in severe dependency (25.3% versus 49.6%). Differences in overall outcome between groups of varying prestroke functional dependency level were statistically significant (P < .05) at all follow-up time points. CONCLUSIONS There was great heterogeneity between groups of different level of prestroke dependency; those of moderate dependency had a relatively favorable prognosis. Patients of different prestroke level of dependency need to be addressed separately, and further research is needed characterizing this group and exploring management strategies.
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Affiliation(s)
- Stefan Sennfält
- Stroke Policy and Quality Register Research GroupLund UniversityLundSweden
- Department of NeurologySkåne University HospitalLundSweden
| | | | - Bo Norrving
- Stroke Policy and Quality Register Research GroupLund UniversityLundSweden
- Department of NeurologySkåne University HospitalLundSweden
| | - Teresa Ullberg
- Stroke Policy and Quality Register Research GroupLund UniversityLundSweden
- Department of NeurologySkåne University HospitalLundSweden
| | - Jesper Petersson
- Stroke Policy and Quality Register Research GroupLund UniversityLundSweden
- Department of NeurologySkåne University HospitalLundSweden
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Kelly DM, Rothwell PM. Impact of multimorbidity on risk and outcome of stroke: Lessons from chronic kidney disease. Int J Stroke 2020; 16:758-770. [PMID: 33243088 PMCID: PMC8521355 DOI: 10.1177/1747493020975250] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
With both an aging population and greater post-stroke survival, multimorbidity is a growing healthcare challenge, affecting over 40% of stroke patients, and rising rapidly and predictably with increasing age. Commonly defined as the co-occurrence of two or more chronic conditions, multimorbidity burden is a strong adverse prognostic factor, associated with greater short- and long-term stroke mortality, worse rehabilitation outcomes, and reduced use of secondary prevention. Chronic kidney disease can be considered as the archetypal comorbidity, being age-dependent and also affecting about 40% of stroke patients. Chronic kidney disease and stroke share very similar traditional cardiovascular risk factor profiles such as hypertension and diabetes, though novel chronic kidney disease-specific risk factors such as inflammation and oxidative stress have also been proposed. Using chronic kidney disease as an exemplar condition, we explore the mechanisms of risk in multimorbidity, implications for management, impact on stroke severity, and downstream consequences such as post-stroke cognitive impairment and dementia.
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Affiliation(s)
- Dearbhla M Kelly
- Nuffield Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, John Radcliffe Hospital, University of Oxford, UK
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, John Radcliffe Hospital, University of Oxford, UK
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38
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Ganesh A, Varma M. Reader response: Sex differences in treatment and outcome after stroke: Pooled analysis including 19,000 participants. Neurology 2020; 95:986-987. [DOI: 10.1212/wnl.0000000000011041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Regenhardt RW, Young MJ, Etherton MR, Das AS, Stapleton CJ, Patel AB, Lev MH, Hirsch JA, Rost NS, Leslie-Mazwi TM. Toward a more inclusive paradigm: thrombectomy for stroke patients with pre-existing disabilities. J Neurointerv Surg 2020; 13:865-868. [PMID: 33127734 DOI: 10.1136/neurintsurg-2020-016783] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/26/2020] [Accepted: 10/04/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Persons with pre-existing disabilities represent over one-third of acute stroke presentations, but account for a far smaller proportion of those receiving endovascular thrombectomy (EVT) and thrombolysis. This is despite existing ethical, economic, legal, and social directives to maximize equity for this vulnerable population. We sought to determine associations between baseline modified Rankin Scale (mRS) and outcomes after EVT. METHODS Individuals who underwent EVT were identified from a prospectively maintained database. Demographics, medical history, presentations, treatments, and outcomes were recorded. Baseline disability was defined as baseline mRS≥2. Accumulated disability was defined as the delta between baseline mRS and absolute 90-day mRS. RESULTS Of 381 individuals, 49 had baseline disability (five with mRS=4, 23 mRS=3, 21 mRS=2). Those with baseline disability were older (81 vs 68 years, P<0.0001), more likely female (65% vs 49%, P=0.032), had more coronary disease (39% vs 20%, P=0.006), stroke/TIA history (35% vs 15%, P=0.002), and higher NIH Stroke Scale (19 vs 16, P=0.001). Baseline mRS was associated with absolute 90-day mRS ≤2 (OR=0.509, 95%CI=0.370-0.700). However, baseline mRS bore no association with accumulated disability by delta mRS ≤0 (ie, return to baseline, OR=1.247, 95%CI=0.943-1.648), delta mRS ≤1 (OR=1.149, 95%CI=0.906-1.458), delta mRS ≤2 (OR 1.097, 95% CI 0.869-1.386), TICI 2b-3 reperfusion (OR=0.914, 95%CI=0.712-1.173), final infarct size (P=0.853, β=-0.014), or intracerebral hemorrhage (OR=0.521, 95%CI=0.244-1.112). CONCLUSIONS While baseline mRS was associated with absolute 90-day disability, there was no association with accumulated disability or other outcomes. Patients with baseline disability should not be routinely excluded from EVT based on baseline mRS alone.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA .,Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J Young
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark R Etherton
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael H Lev
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Cooray C, Karlinski M, Kobayashi A, Ringleb P, Kõrv J, Macleod MJ, Dixit A, Azevedo E, Bladin C, Ahmed N. Safety and early outcomes after intravenous thrombolysis in acute ischemic stroke patients with prestroke disability. Int J Stroke 2020; 16:710-718. [PMID: 32878588 DOI: 10.1177/1747493020954605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There are limited data on intravenous thrombolysis treatment in ischemic stroke patients with prestroke disability. AIM We aimed to evaluate safety and outcomes of intravenous thrombolysis treatment in stroke patients with prestroke disability. METHODS We analyzed 88,094 patients treated with intravenous thrombolysis, recorded in the Safe Implementation of Treatments in Stroke (SITS) International Thrombolysis Register between January 2003 and December 2017, with available NIHSS data at stroke-onset and after 24 h. Of them, 4566 patients (5.2%) had prestroke disability, defined as a modified Rankin Scale score of 3-5. Safety outcome measures included Symptomatic Intracerebral Hemorrhage, any type of parenchymal hematoma on 24 h imaging scans irrespective of clinical symptoms, and death within seven days. Early outcome measures were 24-h NIHSS improvement (≥4 from baseline to 24 h). RESULTS Patients with prestroke disability were older, had more severe strokes, and more comorbidities than patients without prestroke disability. When comparing patients with prestroke disability with patients without prestroke disability, there was however no significant increase in adjusted odds for symptomatic intracerebral hemorrhage (adjusted odds ratio 0.83 (95% CI 0.60-1.15) (absolute difference in proportion 1.17% vs. 1.27%)) or for parenchymal hemorrhage (adjusted odds ratio 0.96 (0.83-1.11) (7.51% vs. 6.34%)). The prestroke disability group had a significantly lower-adjusted odds ratio for a 24-h NIHSS improvement (adjusted odds ratio 0.79 (0.73-0.85) (45.95% vs. 48.45%)) and a higher adjusted odds ratio for seven-day mortality (aOR 1.40 (1.21-1.61) (10.40% vs. 4.93%)). CONCLUSIONS Intravenous thrombolysis in acute ischemic stroke patients with prestroke disability was not associated with an increased risk of symptomatic intracerebral hemorrhage or parenchymal hemorrhage. Prestroke disability was however associated with a higher risk of early mortality compared to patients without prestroke disability.
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Affiliation(s)
- Charith Cooray
- Department of Clinical Neurosciences, Karolinska Institutet, Stockholm, Sweden.,Department of Neurophysiology, Karolinska University Hospital, Stockholm, Sweden
| | - Michal Karlinski
- Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Adam Kobayashi
- Department of Neurology, Interventional Stroke Treatment Center, Center for Treatment of Multiple Sclerosis, Faculty of Medical and Health Sciences, Kazimierz Pulaski University of Technology and Humanities, Radom, Poland
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - Mary J Macleod
- Division of Applied Medicine, University of Aberdeen, Aberdeen, UK
| | - Anand Dixit
- University of Newcastle upon Tyne and Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Elsa Azevedo
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal.,0Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Christopher Bladin
- 1Public Health Group, Stroke Division, Florey Institute of Neuroscience and Mental Health, the University of Melbourne, Australia
| | - Niaz Ahmed
- Department of Clinical Neurosciences, Karolinska Institutet, Stockholm, Sweden
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Ganesh A, Luengo-Fernandez R, Rothwell PM. Late functional improvement and 5-year poststroke outcomes: a population-based cohort study. J Neurol Neurosurg Psychiatry 2020; 91:831-839. [PMID: 32576613 PMCID: PMC7402458 DOI: 10.1136/jnnp-2019-322365] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 03/24/2020] [Accepted: 05/27/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Late functional improvement between 3 and 12 months poststroke occurs in about one in four patients with ischaemic stroke, more commonly in lacunar strokes. It is unknown whether this late improvement is associated with better long-term clinical or health economic outcomes. METHODS In a prospective, population-based cohort of 1-year ischaemic stroke survivors (Oxford Vascular Study; 2002-2014), we examined changes in functional status (modified Rankin Scale (mRS), Rivermead Mobility Index (RMI), Barthel Index (BI)) from 3 to 12 months poststroke. We used Cox regressions adjusted for age, sex, 3-month disability and stroke subtype (lacunar vs non-lacunar) to examine the association of late improvement (by ≥1 mRS grades, ≥1 RMI points and/or ≥2 BI points between 3 and 12 months) with 5-year mortality and institutionalisation. We used similarly adjusted generalised linear models to examine association with 5-year healthcare/social-care costs. RESULTS Among 1288 one-year survivors, 1135 (88.1%) had 3-month mRS >0, of whom 319 (28.1%) demonstrated late functional improvement between 3 and 12 months poststroke. Late improvers had lower 5-year mortality (aHR per mRS=0.68, 95% CI 0.51 to 0.91, p=0.009), institutionalisation (aHR 0.48, 0.33 to 0.72, p<0.001) and healthcare/social care costs (margin US$17 524, -24 763 to -10 284, p<0.001). These associations remained on excluding patients with recurrent strokes during follow-up (eg, 5-year mortality/institutionalisation: aHR 0.59, 0.44 to 0.79, p<0.001) and on examining late improvement per RMI and/or BI (eg, 5-year mortality/institutionalisation with RMI/BI: aHR 0.73, 0.58 to 0.92, p=0.008). CONCLUSION Late functional improvement poststroke is associated with lower 5-year mortality, institutionalisation rates and healthcare/social care costs. These findings should motivate patients and clinicians to maximise late recovery in routine practice, and to consider extending access to proven rehabilitative therapies during the first year poststroke.
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Affiliation(s)
- Aravind Ganesh
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Ramon Luengo-Fernandez
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Peter Malcolm Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Endovascular Therapy or Alteplase in Patients with Comorbidities: Insights from UNMASK EVT. Can J Neurol Sci 2020; 48:77-86. [PMID: 32684179 DOI: 10.1017/cjn.2020.158] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Decisions to treat large-vessel occlusion with endovascular therapy (EVT) or intravenous alteplase depend on how physicians weigh benefits against risks when considering patients' comorbidities. We explored EVT/alteplase decision-making by stroke experts in the setting of comorbidity/disability. METHODS In an international multi-disciplinary survey, experts chose treatment approaches under current resources and under assumed ideal conditions for 10 of 22 randomly assigned case scenarios. Five included comorbidities (cancer, cardiac/respiratory/renal disease, mild cognitive impairment [MCI], physical dependence). We examined scenario/respondent characteristics associated with EVT/alteplase decisions using multivariable logistic regressions. RESULTS Among 607 physicians (38 countries), EVT was chosen less often in comorbidity-related scenarios (79.6% under current resources, 82.7% assuming ideal conditions) versus six "level-1A" scenarios for which EVT/alteplase was clearly indicated by current guidelines (91.1% and 95.1%, respectively, odds ratio [OR] [current resources]: 0.38, 95% confidence interval 0.31-0.47). However, EVT was chosen more often in comorbidity-related scenarios compared to all other 17 scenarios (79.6% versus 74.4% under current resources, OR: 1.34, 1.17-1.54). Responses favoring alteplase for comorbidity-related scenarios (e.g. 75.0% under current resources) were comparable to level-1A scenarios (72.2%) and higher than all others (60.4%). No comorbidity independently diminished EVT odds when considering all scenarios. MCI and dependence carried higher alteplase odds; cancer and cardiac/respiratory/renal disease had lower odds. Being older/female carried lower EVT odds. Relevant respondent characteristics included performing more EVT cases/year (higher EVT-, lower alteplase odds), practicing in East Asia (higher EVT odds), and in interventional neuroradiology (lower alteplase odds vs neurology). CONCLUSION Moderate-to-severe comorbidities did not consistently deter experts from EVT, suggesting equipoise about withholding EVT based on comorbidities. However, alteplase was often foregone when respondents chose EVT. Differences in decision-making by patient age/sex merit further study.
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Wang X, Moullaali TJ, Li Q, Berge E, Robinson TG, Lindley R, Zheng D, Delcourt C, Arima H, Song L, Chen X, Yang J, Chalmers J, Anderson CS, Sandset EC. Utility-Weighted Modified Rankin Scale Scores for the Assessment of Stroke Outcome: Pooled Analysis of 20 000+ Patients. Stroke 2020; 51:2411-2417. [PMID: 32640944 DOI: 10.1161/strokeaha.119.028523] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Patient-centered care prioritizes patient beliefs and values towards wellbeing. We aimed to map functional status (modified Rankin Scale [mRS] scores) and health-related quality of life on the European Quality of Life 5-dimensional questionnaire (EQ-5D) to derive utility-weighted (UW) stroke outcome measures and test their statistical properties and construct validity. METHODS UW-mRS scores were derived using linear regression, with mRS as a discrete ordinal explanatory response variable in 8 large international acute stroke trials. Linear regression models were used to validate UW-mRS scores by assessing differences in mean UW-mRS scores between the treatment groups of each trial. To explore the variability in EQ-5D between individual mRS categories, we generated receiver operator characteristic curves for EQ-5D to differentiate between sequential mRS categories and misclassification matrix to classify individual patients into a matched mRS category based on the closest UW-mRS value to their observed individual EQ-5D value. RESULTS Among 22 946 acute stroke patients, derived UW-mRS across mRS scores 0 to 6 were 0.96, 0.83, 0.72, 0.54, 0.22, -0.18, and 0, respectively. Both UW-mRS and ordinal mRS scores captured divergent treatment effects across all 8 acute stroke trials. The sample sizes required to detect the treatment effects using UW-mRS scores as a continuous variable were almost half that required in trials for a binary cut point on the mRS. Area under receiver operator characteristic curves based on EQ-5D utility values varied from 0.66 to 0.81. Misclassification matrix showed moderate agreement between actual and matched mRS scores (kappa, 0.68 [95% CI, 0.67-0.68]). CONCLUSIONS Medical strategies that target avoiding dependency may provide maximum benefit in terms of poststroke health-related quality of life. Despite variable differences with mRS scores, the UW-mRS provides efficiency gains as a smaller sample size is required to detect a treatment effect in acute stroke trials through use of continuous scores. Registration: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT00226096, NCT00716079, NCT01422616, NCT02162017, NCT00120003, NCT02123875. URL: http://ctri.nic.in; Unique identifier: CTRI/2013/04/003557. URL: https://www.isrctn.com; Unique identifier: ISRCTN89712435.
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Affiliation(s)
- Xia Wang
- The George Institute for Global Health, University of New South Wales, Australia (X.W., Q.L., R.L., D.Z., C.D., X.C., J.C., C.S.A.)
| | - Tom J Moullaali
- University of Leicester, Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, United Kingdom (T.G.R.)
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Australia (X.W., Q.L., R.L., D.Z., C.D., X.C., J.C., C.S.A.)
| | - Eivind Berge
- Department of Cardiology, Oslo University Hospital, Norway (E.B.)
| | - Thompson G Robinson
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (T.J.M.)
| | - Richard Lindley
- The George Institute for Global Health, University of New South Wales, Australia (X.W., Q.L., R.L., D.Z., C.D., X.C., J.C., C.S.A.).,Westmead Hospital, University of Sydney, NSW, Australia (R.L.)
| | - Danni Zheng
- The George Institute for Global Health, University of New South Wales, Australia (X.W., Q.L., R.L., D.Z., C.D., X.C., J.C., C.S.A.)
| | - Candice Delcourt
- The George Institute for Global Health, University of New South Wales, Australia (X.W., Q.L., R.L., D.Z., C.D., X.C., J.C., C.S.A.).,Sydney Medical School, The University of Sydney, Australia (C.D.).,Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia (C.D., C.S.A.)
| | - Hisatomi Arima
- Department of Public Health, Fukuoka University, Japan (H.A.)
| | - Lili Song
- The George Institute China at Peking University Health Science Centre, Beijing, PR China (L.S., C.S.A.)
| | - Xiaoying Chen
- The George Institute for Global Health, University of New South Wales, Australia (X.W., Q.L., R.L., D.Z., C.D., X.C., J.C., C.S.A.)
| | - Jie Yang
- Department of Neurology, the First Affiliated Hospital of Chengdu Medical College, China (J.Y.)
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Australia (X.W., Q.L., R.L., D.Z., C.D., X.C., J.C., C.S.A.)
| | - Craig S Anderson
- The George Institute for Global Health, University of New South Wales, Australia (X.W., Q.L., R.L., D.Z., C.D., X.C., J.C., C.S.A.).,Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia (C.D., C.S.A.).,The George Institute China at Peking University Health Science Centre, Beijing, PR China (L.S., C.S.A.)
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Larsson A, Karlsson C, Rentzos A, Schumacher M, Abrahamson M, Allardt A, Brederlau A, Ceder E, Davidson M, Dunker D, Gunnarsson T, Holmegaard L, Jerndal M, Karlsson JE, Nordanstig A, Redfors P, Rosengren L, Tatlisumak T, Jood K. Do patients with large vessel occlusion ischemic stroke harboring prestroke disability benefit from thrombectomy? J Neurol 2020; 267:2667-2674. [PMID: 32410019 PMCID: PMC7419353 DOI: 10.1007/s00415-020-09882-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 04/28/2020] [Accepted: 04/30/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Evidence of endovascular treatment (EVT) for acute large vessel occlusion (LVO) ischemic stroke in patients harboring substantial prestroke disability is lacking due to their exclusion from randomized trials. Here, we used routine care observational data to compare outcomes in patients with and without prestroke disability receiving EVT for LVO ischemic stroke. METHODS Consecutive patients undergoing EVT for acute LVO ischemic stroke at the Sahlgrenska University Hospital from January 1st, 2015 to March 31st, 2018 were registered in the Sahlgrenska Stroke Recanalization Registry. Pre- and poststroke functional levels were assessed by the modified Rankin Scale (mRS). Outcomes were recanalization rate (mTICI = 2b/3), symptomatic intracranial hemorrhage [sICH], complications during hospital stay, and return to prestroke functional level and mortality at 3 months. RESULTS Among 591 patients, 90 had prestroke disability (mRS ≥ 3). The latter group were older, more often female, had more comorbidities and higher NIHSS scores before intervention compared to patients without prestroke disability. Recanalization rates (80.0% vs 85.0%, p = 0.211), sICH (2.2% vs 6.3% p = 0.086) and the proportion of patients returning to prestroke functional level (22.7% vs 14.8% p = 0.062) did not significantly differ between those with and without prestroke disability. Patients with prestroke disability had higher complication rates during hospital stay (55.2% vs 40.1% p < 0.01) and mortality at 3 months (48.9% vs 24.3% p < 0.001). CONCLUSION One of five with prestroke disability treated with thrombectomy for a LVO ischemic stroke returned to their prestroke functional level. However, compared to patients without prestroke disability, mortality at 3 months was higher.
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Affiliation(s)
- Alice Larsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Blå stråket 7, plan 3, 413 45, Göteborg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Camilla Karlsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Blå stråket 7, plan 3, 413 45, Göteborg, Sweden
| | - Alexandros Rentzos
- Department of Radiology, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
- Department of Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Marcus Schumacher
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Blå stråket 7, plan 3, 413 45, Göteborg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
| | | | - Arne Allardt
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Anke Brederlau
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Blå stråket 7, plan 3, 413 45, Göteborg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Erik Ceder
- Department of Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Maria Davidson
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Dennis Dunker
- Department of Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Thorsteinn Gunnarsson
- Department of Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Lukas Holmegaard
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Blå stråket 7, plan 3, 413 45, Göteborg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Mikael Jerndal
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Jan-Erik Karlsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Blå stråket 7, plan 3, 413 45, Göteborg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Annika Nordanstig
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Blå stråket 7, plan 3, 413 45, Göteborg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Blå stråket 7, plan 3, 413 45, Göteborg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Lars Rosengren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Blå stråket 7, plan 3, 413 45, Göteborg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Blå stråket 7, plan 3, 413 45, Göteborg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Katarina Jood
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Blå stråket 7, plan 3, 413 45, Göteborg, Sweden.
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden.
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Salwi S, Cutting S, Salgado AD, Espaillat K, Fusco MR, Froehler MT, Chitale RV, Kirshner H, Schrag M, Jasne A, Burton T, MacGrory B, Saad A, Jayaraman MV, Madsen TE, Dakay K, McTaggart R, Yaghi S, Khatri P, Mistry AM, Mistry EA. Mechanical Thrombectomy in Patients With Ischemic Stroke With Prestroke Disability. Stroke 2020; 51:1539-1545. [PMID: 32268851 PMCID: PMC7367056 DOI: 10.1161/strokeaha.119.028246] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background and Purpose- We aimed to compare functional and procedural outcomes of patients with acute ischemic stroke with none-to-minimal (modified Rankin Scale [mRS] score, 0-1) and moderate (mRS score, 2-3) prestroke disability treated with mechanical thrombectomy. Methods- Consecutive adult patients undergoing mechanical thrombectomy for an anterior circulation stroke were prospectively identified at 2 comprehensive stroke centers from 2012 to 2018. Procedural and 90-day functional outcomes were compared among patients with prestroke mRS scores 0 to 1 and 2 to 3 using χ2, logistic, and linear regression tests. Primary outcome and significant differences in secondary outcomes were adjusted for prespecified covariates. Results- Of 919 patients treated with mechanical thrombectomy, 761 were included and 259 (34%) patients had moderate prestroke disability. Ninety-day mRS score 0 to 1 or no worsening of prestroke mRS was observed in 36.7% and 26.7% of patients with no-to-minimal and moderate prestroke disability, respectively (odds ratio, 0.63 [0.45-0.88], P=0.008; adjusted odds ratio, 0.90 [0.60-1.35], P=0.6). No increase in the disability at 90 days was observed in 22.4% and 26.7%, respectively. Rate of symptomatic intracerebral hemorrhage (7.3% versus 6.2%, P=0.65), successful recanalization (86.7% versus 83.8%, P=0.33), and median length of hospital stay (5 versus 5 days, P=0.06) were not significantly different. Death by 90 days was higher in patients with moderate prestroke disability (14.3% versus 40.3%; odds ratio, 4.06 [2.82-5.86], P<0.001; adjusted odds ratio, 2.83 [1.84, 4.37], P<0.001). Conclusions- One-third of patients undergoing mechanical thrombectomy had a moderate prestroke disability. There was insufficient evidence that functional and procedural outcomes were different between patients with no-to-minimal and moderate prestroke disability. Patients with prestroke disability were more likely to die by 90 days.
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Affiliation(s)
- Sanjana Salwi
- School of Medicine, Vanderbilt University, Nashville, TN
| | | | | | | | | | | | | | | | | | - Adam Jasne
- Yale University School of Medicine, New Haven, CT
| | | | | | - Ali Saad
- Rhode Island Hospital, Providence, RI
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Guan S, Zhang X, Liu H, Zhang Y, Hou C, Ji X, Fang X. Is functional disability a risk equivalent to the comorbidity of multi-vascular risk factors for cardiovascular events and all-cause death? A 5-year follow-up study. Top Stroke Rehabil 2020; 27:553-562. [PMID: 32172677 DOI: 10.1080/10749357.2020.1738661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background/objectives: Functional disability (FD) is common after stroke and associated with the occurrence of future adverse events; however, whether FD is as strong a risk factor as comorbid vascular risk factors for cardiovascular events and death is unclear. Methods: Consecutive patients 3-6 months after index ischemic stroke were assessed at baseline and followed up for documented new cardiovascular events (recurrent stroke, acute myocardial infarction, and sudden death) and death within 5 years. Comorbidity of vascular risk factors was stratified as low or intermediate-to-high risk according to the Stroke Prognostic Instrument II. Four mutually exclusive cohorts were identified (1) intermediate-to-high risk only, n = 505, (2) FD only, n = 78, (3) both intermediate-to-high risk and FD, n = 264, and (4) low risk and no FD, n = 240. Results: The incidence of cardiovascular events was lowest in patients free of FD with low risk, followed by patients with FD alone, intermediate-to-high risk alone, and both. Compared with intermediate-to-high risk only, patients free of FD with low risk had a significantly lower adjusted hazard ratio (HR) (HR: 0.56, 95% confidence interval [CI]: 0.33-0.94), patients with FD only had a similar HR (HR: 0.47, 95% CI: 0.19 -1.18), and patients with both FD and intermediate-to-high risk had a significantly higher HR (HR: 2.13, 95% CI: 1.53-2.98) of cardiovascular events. A similar trend but a larger HR was noted for all-cause death. Conclusion: FD 3-6 months after ischemic stroke is a risk equivalent to comorbidity of conventional vascular risk factors for the incidence of cardiovascular events and mortality of all-cause death.
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Affiliation(s)
- Shaochen Guan
- Evidence-based Medical Center, Xuanwu Hospital, Capital Medical University , Beijing, China
| | - Xinqing Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University , Beijing, China
| | - Hongjun Liu
- Evidence-based Medical Center, Xuanwu Hospital, Capital Medical University , Beijing, China
| | - Yanlei Zhang
- Department of Geriatrics, Xuanwu Hospital, Capital Medical University , Beijing, China
| | - Chengbei Hou
- Evidence-based Medical Center, Xuanwu Hospital, Capital Medical University , Beijing, China
| | - Xunming Ji
- Department of Geriatrics, Xuanwu Hospital, Capital Medical University , Beijing, China
| | - Xianghua Fang
- Evidence-based Medical Center, Xuanwu Hospital, Capital Medical University , Beijing, China
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47
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Li J, Wang J, Wu B, Xu H, Wu X, Zhou L, Deng B. Association Between Early Cognitive Impairment and Midterm Functional Outcomes Among Chinese Acute Ischemic Stroke Patients: A Longitudinal Study. Front Neurol 2020; 11:20. [PMID: 32174878 PMCID: PMC7054458 DOI: 10.3389/fneur.2020.00020] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 01/08/2020] [Indexed: 01/22/2023] Open
Abstract
Background: Cognitive decline is common after stroke. The influence of early cognitive impairment on midterm functional outcomes among Chinese acute ischemic stroke (AIS) patients has not been fully studied. The aim of the study was to assess the association between early cognitive impairment and midterm functional outcomes among Chinese AIS patients. Methods: A longitudinal survey focusing on Chinese AIS patients was conducted in three stroke centers in Shanghai, China (July to December 2016). A total of 185 eligible patients were interviewed at acute stage and at 1, 3, and 6 months after onset. Patients' functional outcomes were measured by modified Rankin Scale (mRS) and Barthel Index (BI) at each time point. Cognitive function was assessed using Montreal Cognitive Assessment, Changsha version (MoCA-CS), within 7 days after stroke onset. Covariates included patient's demographic characteristics, socioeconomic status, clinical characteristics of stroke, vascular risk factors, receiving rehabilitation after discharge from acute hospital, and recurrence. Generalized linear mixed models and general linear mixed models were applied. Results: The prevalence of cognitive impairment at acute stage of stroke among these patients was 88.1%. The risk of disability (mRS 2–5) of all patients after stroke decreased over time (OR = 0.491, 95% CI = 0.401–0.603). The risk of disability among those with cognitive impairment increased compared with those with normal cognition (OR = 7.384, 95% CI = 1.041–52.407). The BI score of all patients increased over time after controlling for covariates (β = 1.51, p < 0.01). The BI score of those with cognitive impairment was lower than that with normal cognition over the follow-up period after controlling for other covariates (β = −8.11, p < 0.05). Conclusions: This study showed that early cognitive impairment was associated with higher risk of disability and poor activity of daily living (ADL) among Chinese AIS patients. Further studies are needed to examine the linkage between multi-domain cognitive impairment and long-term disability and ADL among stroke survivors by using neuropsychological test batteries.
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Affiliation(s)
- Juan Li
- Naval Military Medical University School of Nursing, Shanghai, China
| | - Jing Wang
- Fudan University School of Nursing, Shanghai, China
| | - Bei Wu
- New York University Rory Meyers College of Nursing, New York, NY, United States
| | - Hanzhang Xu
- Duke University School of Nursing, Durham, NC, United States.,Duke University School of Medicine, Durham, NC, United States
| | - Xiongfeng Wu
- Stroke Center, Changhai Hospital Affiliated to Naval Military Medical University, Shanghai, China
| | - Lanshu Zhou
- Naval Military Medical University School of Nursing, Shanghai, China
| | - Benqiang Deng
- Stroke Center, Changhai Hospital Affiliated to Naval Military Medical University, Shanghai, China
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48
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Young MJ, Regenhardt RW, Leslie-Mazwi TM, Stein MA. Disabling stroke in persons already with a disability: Ethical dimensions and directives. Neurology 2020; 94:306-310. [PMID: 31969466 DOI: 10.1212/wnl.0000000000008964] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/21/2019] [Indexed: 12/22/2022] Open
Abstract
Stroke is the second leading cause of death worldwide and a leading cause of adult disability worldwide. More than a third of individuals presenting with strokes are estimated to have a preexisting disability. Despite unprecedented advances in stroke research and clinical practice over the past decade, approaches to acute stroke care for persons with preexisting disability have received scant attention. Current standards of research and clinical practice are influenced by an underexplored range of biases that may hinder acute stroke care for persons with disability. These trends may exacerbate unequal health outcomes by rendering novel stroke therapies inaccessible to many persons with disabilities. Here, we explore the underpinnings and implications of biases involving persons with disability in stroke research and practice. Recent insights from bioethics, disability rights, and health law are explained and critically evaluated in the context of prevailing research and clinical practices. Allowing disability to drive decisions to withhold acute stroke interventions may perpetuate disparate health outcomes and undermine ethically resilient stroke care. Advocacy for inclusion of persons with disability in future stroke trials can improve equity in stroke care delivery.
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Affiliation(s)
- Michael J Young
- From the Departments of Neurology (M.J.Y., R.W.R., T.M.L.-M.) and Neurosurgery (T.M.L.-M.), Massachusetts General Hospital, Harvard Medical School; and Harvard Law School (M.A.S.), Boston, MA.
| | - Robert W Regenhardt
- From the Departments of Neurology (M.J.Y., R.W.R., T.M.L.-M.) and Neurosurgery (T.M.L.-M.), Massachusetts General Hospital, Harvard Medical School; and Harvard Law School (M.A.S.), Boston, MA
| | - Thabele M Leslie-Mazwi
- From the Departments of Neurology (M.J.Y., R.W.R., T.M.L.-M.) and Neurosurgery (T.M.L.-M.), Massachusetts General Hospital, Harvard Medical School; and Harvard Law School (M.A.S.), Boston, MA
| | - Michael Ashley Stein
- From the Departments of Neurology (M.J.Y., R.W.R., T.M.L.-M.) and Neurosurgery (T.M.L.-M.), Massachusetts General Hospital, Harvard Medical School; and Harvard Law School (M.A.S.), Boston, MA
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49
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Caruso P, Ajčević M, Furlanis G, Ridolfi M, Lugnan C, Cillotto T, Naccarato M, Manganotti P. Thrombolysis safety and effectiveness in acute ischemic stroke patients with pre-morbid disability. J Clin Neurosci 2019; 72:180-184. [PMID: 31875830 DOI: 10.1016/j.jocn.2019.11.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/30/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Recombinant tissue plasminogen activator (rt-PA) is the first-line therapy demonstrated to be safe and effective in acute ischemic stroke. People with pre-existing severe dementia or physical disability are usually excluded from rt-PA. The aim of our study was to investigate rt-PA safety and effectiveness in acute stroke with pre-existing disability (mRS ≥ 2). METHODS The study encompassed 35 acute ischemic stroke patients with mRS ≥ 2 treated with rt-PA. In order to assess the differences in clinical outcome in three disability groups (mRS = 2; 3; 4/5), the following parameters were evaluated: intracerebral hemorrhage, mortality, NIHSS, ΔNIHSS and mRS. RESULTS Baseline-NIHSS and age were not significantly different among groups. Mortality was higher in the pre-morbid mRS 4/5 group (44%) than in the pre-morbid mRS2 (16.7%) and mRS 3 groups (21.4%). In survived patients, median ΔNIHSS% was higher in the mRS2 and 3 groups (-63.3% and -92.3%, respectively) than in the mRS4/5 group (-9.1%). The 247 rt-PA treated subjects with mRS < 2 in the same period showed lower mortality rate (4.7%), lower sICH (5%), lower mRS at discharge (median 1; range 0-6) and similar ΔNIHSS% (-75%). CONCLUSION Patients with mRS 2 and 3 may benefit from rt-PA with a moderate risk of sICH and mortality.
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Affiliation(s)
- Paola Caruso
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy.
| | - Miloš Ajčević
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy; NEUROFARBA Department, Neuroscience Section, University of Florence, Italy; Department of Engineering and Architecture, University of Trieste, Trieste, Italy
| | - Giovanni Furlanis
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Mariana Ridolfi
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Carlo Lugnan
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Tommaso Cillotto
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Marcello Naccarato
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
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50
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Gumbinger C, Ringleb P, Ippen F, Ungerer M, Reuter B, Bruder I, Daffertshofer M, Stock C. Outcomes of patients with stroke treated with thrombolysis according to prestroke Rankin Scale scores. Neurology 2019; 93:e1834-e1843. [PMID: 31653709 DOI: 10.1212/wnl.0000000000008468] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 06/18/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND It is common practice to withhold IV thrombolysis (IVT) for acute ischemic stroke in patients with preexisting disabilities. To test the hypothesis of an association of IVT and good clinical outcome also in patients with preexisting disabilities without an increase in mortality, we analyzed data from 52,741 patients (15,317 treated with IVT) depending on prestroke Rankin Scale (pRS) score. METHODS We performed an observational study based on a consecutive stroke registry covering 10.8 million inhabitants. The outcome at discharge of patients with stroke admitted in the time window of potential eligibility for IVT (<4.5 hours after stroke onset) was compared between patients treated and those not treated with thrombolysis, stratified by pRS score. Logistic regression analysis was used to estimate adjusted odds ratios (ORs) along with 95% confidence intervals (CIs) for favorable clinical outcome, defined as returning to the baseline pRS score or a score of 0 or 1 and mortality. Sensitivity analyses for subgroups of mildly and severely affected patients with stroke were performed, and the influence of treatment duration was assessed. RESULTS Among included patients, IVT rates were 32% for patients with pRS scores of 0 to 1 and 20% for patients with pRS scores of 2 to 5. IVT in patients with pRS scores of 0 to 4 was associated with a higher chance of returning to the baseline pRS score (or a modified Rankin Scale score of 0/1), with ORs ranging between 1.42 (pRS score 2; 95% CI 1.16-1.73) and 1.73 (pRS score 0; 95% CI 1.61-1). The OR observed in patients with a pRS score of 5 was 0.65 (95% CI 0.25-1.70). Observed associations remained consistent in sensitivity analyses. Subgroup analyses revealed no evidence of bias due to potential floor and ceiling effects. No evidence of elevated in-hospital mortality of patients treated with thrombolysis was observed. CONCLUSIONS Our study suggests that IVT can be effective even in patients with severe preexisting disabilities, provided that they were not bedridden before stroke onset. Withholding IVT on the sole ground of prestroke disabilities may not be justified.
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Affiliation(s)
- Christoph Gumbinger
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany.
| | - Peter Ringleb
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany
| | - Franziska Ippen
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany
| | - Matthias Ungerer
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany
| | - Björn Reuter
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany
| | - Ingo Bruder
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany
| | - Michael Daffertshofer
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany
| | - Christian Stock
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany
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