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Strååt K, Isaksson E, Laska AC, Rooth E, Svennberg E, Åsberg S, Wester P, Engdahl J. Large variations in atrial fibrillation screening practice after ischemic stroke and transient ischemic attack in Sweden: a survey study. BMC Neurol 2024; 24:120. [PMID: 38605308 PMCID: PMC11007877 DOI: 10.1186/s12883-024-03622-2] [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: 05/04/2023] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Atrial fibrillation (AF) screening after ischemic stroke or transient ischemic attack (TIA) is given high priority in clinical guidelines. However, patient selection, electrocardiogram (ECG) modality and screening duration remains undecided and current recommendations vary. METHODS The aim of this study was to investigate the clinical practice of AF screening after ischemic stroke or TIA at Swedish stroke units. In collaboration with the stakeholders of the Swedish Stroke Register (Riksstroke) a digital survey was drafted, then tested and revised by three stroke consultants. The survey consisted of 17 multiple choice/ free text questions and was sent by e-mail to the medical directors at all stroke units in Sweden. RESULTS All 72 stroke units in Sweden responded to the survey. Most stroke units reported that ≥ 75% of ischemic stroke (69/72 stroke units) or TIA patients (67/72 stroke units), without previously known AF, were screened for AF. Inpatient telemetry ECG was the method of first-choice in 81% of the units, but 7% reported lack of access. A variety of standard monitoring durations were used for inpatient telemetry ECG. The second most common choice was Holter ECG (17%), also with considerable variations in monitoring duration. Other AF screening modalities were used as a first-choice method (handheld and patch ECG) but less frequently. CONCLUSIONS Clinical practice for AF screening after ischemic stroke or TIA differed between Swedish stroke units, both in choice of AF screening methods as well as in monitoring durations. There is an urgent need for evidence and evidence-based recommendations in this field. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Kajsa Strååt
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.
- Department of Cardiology, Danderyd Hospital, Stockholm, SE-182 88, Sweden.
| | - Eva Isaksson
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Ann Charlotte Laska
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Elisabeth Rooth
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Emma Svennberg
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Signild Åsberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Per Wester
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Johan Engdahl
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
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2
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Fernandes C, Sousa JA, Bernardo-Castro S, Silva F, Donato H, Sargento-Freitas J. Early Mobilization Decision after an Acute Ischemic Stroke: Protocol for an Umbrella Review. ACTA MEDICA PORT 2024. [PMID: 38489931 DOI: 10.20344/amp.20715] [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: 10/02/2023] [Accepted: 12/19/2023] [Indexed: 03/17/2024]
Abstract
INTRODUCTION Stroke is considered one of the greatest public health challenges worldwide, with the ischemic subtype being the most prevalent. Various acute stroke clinical guidelines recommend early rehabilitation interventions, including very early mobilization. However, despite the studies conducted in recent years regarding when to initiate mobilization after an acute stroke, there are few systematic and personalized protocols based on the factors for which patient mobilization should ideally be performed. We aim to conduct an umbrella review of systematic reviews and meta-analyses to study the early mobilization decision after an acute ischemic stroke in comparison with conventional care and correlate the different approaches with patient clinical outcomes. METHODS AND ANALYSIS We will perform a systematic search on PubMed/MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Epistemonikos and Web of Science Core Collection databases. Retrieved studies will be independently reviewed by two authors and any discrepancies will be resolved by consensus or with a third reviewer. Reviewers will extract the data and assess the risk of bias in the selected studies. We will use the 16-item Assessment of Multiple Systematic Reviews 2 (AMSTAR2) checklist as the critical appraisal tool to assess cumulative evidence and risk of bias of the different studies. This will be the first umbrella review that compares early mobilization approaches in post-acute ischemic stroke. This study may help to define the optimal early mobilization strategy in stroke patients. PROSPERO registration number: CRD42023430494.
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Affiliation(s)
- Catarina Fernandes
- Serviço de Neurologia. Unidade Local de Saúde de Coimbra. Coimbra. Portugal
| | - João André Sousa
- Serviço de Neurologia. Unidade Local de Saúde de Coimbra. Coimbra. Portugal
| | | | - Fernando Silva
- Serviço de Neurologia. Unidade Local de Saúde de Coimbra. Coimbra. Portugal
| | - Helena Donato
- Documentation and Scientific Information Service. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
| | - João Sargento-Freitas
- Serviço de Neurologia. Unidade Local de Saúde de Coimbra. Coimbra; Faculdade de Medicina. Universidade de Coimbra. Coimbra. Portugal
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3
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Harenberg J, Gosselin RC, Cuker A, Becattini C, Pabinger I, Poli S, Weitz J, Ageno W, Bauersachs R, Celap I, Choi P, Douketis J, Douxfils J, Elalamy I, Falanga A, Fareed J, Favaloro EJ, Gerotziafas G, Herkner H, Hetjens S, Heubner L, Klamroth R, Langer F, Lip GYH, Grory BM, Margetić S, Merrelaar A, Pikta M, Renne T, Schulman S, Schwameis M, Strbian D, Tafur A, Vassart J, Violi F, Walenga J, Weiss C. Algorithm for Rapid Exclusion of Clinically Relevant Plasma Levels of Direct Oral Anticoagulants in Patients Using the DOAC Dipstick: An Expert Consensus Paper. Thromb Haemost 2024. [PMID: 38316416 DOI: 10.1055/a-2261-1811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND With the widespread use of direct oral anticoagulants (DOACs), there is an urgent need for a rapid assay to exclude clinically relevant plasma levels. Accurate and rapid determination of DOAC levels would guide medical decision-making to (1) determine the potential contribution of the DOAC to spontaneous or trauma-induced hemorrhage; (2) identify appropriate candidates for reversal, or (3) optimize the timing of urgent surgery or intervention. METHODS AND RESULTS The DOAC Dipstick test uses a disposable strip to identify factor Xa- or thrombin inhibitors in a urine sample. Based on the results of a systematic literature search followed by an analysis of a simple pooling of five retrieved clinical studies, the test strip has a high sensitivity and an acceptably high negative predictive value when compared with levels measured with liquid chromatography tandem mass spectrometry or calibrated chromogenic assays to reliably exclude plasma DOAC concentrations ≥30 ng/mL. CONCLUSION Based on these data, a simple algorithm is proposed to enhance medical decision-making in acute care indications useful primarily in hospitals not having readily available quantitative tests and 24/7. This algorithm not only determines DOAC exposure but also differentiates between factor Xa and thrombin inhibitors to better guide clinical management.
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Affiliation(s)
- Job Harenberg
- Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- DOASENSE GmbH, Heidelberg, Germany
| | - Robert C Gosselin
- Davis Health System, Thrombosis and Hemostasis Center, University of California, Sacramento, California, United States
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Cecilia Becattini
- Internal and Emergency Medicine -Stroke Unit, University of Perugia, Perugia PG, Italy
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | - Jeffrey Weitz
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Rupert Bauersachs
- GefasCentrum, CCB - Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | - Ivana Celap
- Department of Clinical Chemistry, University Hospital Center Sestre, Zagreb, Croatia
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Croatia
| | - Philip Choi
- Neurosciences, Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Australia
| | - James Douketis
- Department Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Research for Life Sciences, Namur, Belgium
- Qualiblood s.a., Department of Research and Development, Namur, Belgium
| | - Ismail Elalamy
- Service d'Hematologie Biologique Hopital Tenon, Hopitaux Universitaires Est Parisien, Assistance Publique Hopitaux de Paris, Paris, France
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Anna Falanga
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
- University of Milan Bicocca, Monza, Italy
| | - Jawed Fareed
- Department of Molecular Pharmacology & Neuroscience, Loyola University Medical Center, Maywood, Illinois, United States
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Westmead, NSW, Australia
- Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Grigorios Gerotziafas
- INSERM, UMR_S 938, Research Group Cancer, Biology and Therapeutics, Centre de recherche Saint-Antoine (CRSA), Institut Universitaire de Cancerologie, Sorbonne Universite, Paris, France
- Thrombosis Center, Tenon-Saint Antoine, Hopitaux Universitaires de l'Est Parisien, Assistance Publique Hopitaux de Paris (APHP), France
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Svetlana Hetjens
- Department of Statistics, Medical Faculty Mannheim, Ruprecht Karls University of Heidelberg, Mannheim, Germany
| | - Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus," Technische Universitat Dresden, Germany
| | - Robert Klamroth
- Vascular Medicine and Haemostaseology, Vivantes Klinikum im Friedrichschain, Berlin, Germany
| | - Forian Langer
- II. Medizinische Klinik und Poliklinik, Universitatsklinikum Eppendorf, Hamburg, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Brian Mac Grory
- Department of Neurology, Duke University, Durham, North Carolina, United States
| | - Sandra Margetić
- GefasCentrum, CCB - Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
- School of Medicine, Catholic University of Croatia, Zagreb, Croatia
| | - Anne Merrelaar
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Marika Pikta
- Department of Laboratory Medicine, North Estonia Medical Centre, Tallinn, Estonia
- Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia
| | - Thomas Renne
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sam Schulman
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
- Thrombosis and Atherosclerosis Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Alfonso Tafur
- Department of Medicine, Vascular Medicine, NorthShore University Health System, Evanston, Illinois, United States
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States
| | - Julie Vassart
- Department of Pharmacy, Namur Research for Life Sciences, Namur, Belgium
| | - Francesco Violi
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Jeanine Walenga
- Cardiovascular Research Institute, Loyola University Chicago, Maywood, Illinois, United States
| | - Christel Weiss
- Department of Statistics, Medical Faculty Mannheim, Ruprecht Karls University of Heidelberg, Mannheim, Germany
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Wardlaw JM, Chabriat H, de Leeuw FE, Debette S, Dichgans M, Doubal F, Jokinen H, Katsanos AH, Ornello R, Pantoni L, Pasi M, Pavlovic AM, Rudilosso S, Schmidt R, Staals J, Taylor-Rowan M, Hussain S, Lindgren AG. European stroke organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke. Eur Stroke J 2024; 9:5-68. [PMID: 38380638 PMCID: PMC10916806 DOI: 10.1177/23969873231219416] [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: 10/04/2023] [Accepted: 11/22/2023] [Indexed: 02/22/2024] Open
Abstract
A quarter of ischaemic strokes are lacunar subtype, typically neurologically mild, usually resulting from intrinsic cerebral small vessel pathology, with risk factor profiles and outcome rates differing from other stroke subtypes. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations to assist with clinical decisions about management of lacunar ischaemic stroke to prevent adverse clinical outcomes. The guideline was developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We addressed acute treatment (including progressive lacunar stroke) and secondary prevention in lacunar ischaemic stroke, and prioritised the interventions of thrombolysis, antiplatelet drugs, blood pressure lowering, lipid lowering, lifestyle, and other interventions and their potential effects on the clinical outcomes recurrent stroke, dependency, major adverse cardiovascular events, death, cognitive decline, mobility, gait, or mood disorders. We systematically reviewed the literature, assessed the evidence and where feasible formulated evidence-based recommendations, and expert concensus statements. We found little direct evidence, mostly of low quality. We recommend that patients with suspected acute lacunar ischaemic stroke receive intravenous alteplase, antiplatelet drugs and avoid blood pressure lowering according to current acute ischaemic stroke guidelines. For secondary prevention, we recommend single antiplatelet treatment long-term, blood pressure control, and lipid lowering according to current guidelines. We recommend smoking cessation, regular exercise, other healthy lifestyle modifications, and avoid obesity for general health benefits. We cannot make any recommendation concerning progressive stroke or other drugs. Large randomised controlled trials with clinically important endpoints, including cognitive endpoints, are a priority for lacunar ischaemic stroke.
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Affiliation(s)
- Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Hugues Chabriat
- CNVT and Department of Neurology, Hopital Lariboisière, Paris, France
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Stéphanie Debette
- Bordeaux Population Health Research Center; University of Bordeaux – Inserm U1219; Bordeaux; Department of Neurology, Institute for Neurodegenerative Diseases, Bordeaux University Hospital, Bordeaux, France
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Medical Center, Munich; Munich Cluster for Systems Neurology (SyNergy), Munich; German Center for Neurodegenerative Diseases (DZNE, Munich), Munich; German Centre for Cardiovascular Research (DZHK, Munich), Munich, Germany
| | - Fergus Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor’s Building, Edinburgh, UK
| | - Hanna Jokinen
- Neurocenter, Helsinki University Hospital and University of Helsinki, HUS, Helsinki, Finland
| | - Aristeidis H Katsanos
- Neurology, McMaster University & Population Health Research Institute, Hamilton, ON, Canada
| | - Raffaele Ornello
- Neurology/Department of Biotechnological ad Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | | | - Marco Pasi
- Department of Neurology, University of Tours, Tours, France
| | - Aleksandra M Pavlovic
- University of Belgrade, Faculty of Special Education and Rehabilitation, Belgrade, Serbia
| | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neurology, Hospital Clínic of Barcelona, Barcelona, Spain
| | | | - Julie Staals
- Department of Neurology and CARIM School for cardiovascular diseases, MUMC+, Maastricht, The Netherlands
| | - Martin Taylor-Rowan
- School of Health and Wellbeing; General Practice and Primary Care, Clarice Pears Building, University of Glasgow, Glasgow, UK
| | | | - Arne G Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University; Department of Neurology, Skåne University Hospital, Lund, Skånes Universitetssjukhus, Lund, Sweden
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5
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Luo W, Xu Y, Liu C, Zhang H. The Influence of the Novel Computer-Aided Triage System Based on Artificial Intelligence on Endovascular Therapy in Patients with Large Vascular Occlusions: A Meta-Analysis. World Neurosurg 2024; 182:200-207.e2. [PMID: 38048961 DOI: 10.1016/j.wneu.2023.11.140] [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: 11/25/2023] [Accepted: 11/28/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE The integration of artificial intelligence (AI) with modern healthcare has become increasingly prominent. The purpose of this study is to explore the impact of the novel computer-aided triage system based on artificial intelligence (AI-CTS) on endovascular therapy (EVT) in patients with large vascular occlusions (LVO). This study marks the first comprehensive systematic review and meta-analysis on the subject. METHODS A comprehensive study was performed on PubMed, Medline, Embase, Cochrane Library, and Chinese databases from their establishment to September 2023, in accordance with PRISMA recommendations. RevMan 5.4 software was used for summative analysis. The outcomes included door-to-groin (DTG) time, time from CT scan initiation to EVT, time from CT scan to reperfusion, and 90-day modified Rankin Scale (mRS). RESULTS A total of 7 studies involving 752 participants were included in the meta-analysis. The pooled results demonstrated that patients in the post-AI group had less time of DTG [SMD, 0.54; 95% CI, 0.40-0.69; P < 0.00001] and CT scan to EVT [SMD, 0.57; 95% CI, 0.42-0.73; P < 0.00001], as well as less time of CTA to recanalization [SMD, 0.63; 95% CI, 0.36-0.90; P < 0.00001]. There was no significant difference between the 2 groups in terms of the mRS at 90 days [OR, 0.66; 95% CI, 0.43-1.01; P = 0.06]. CONCLUSIONS The combination of AI-CTS and EVT has improved the therapy process for LVO patients. However, the improvement in mRS at 90 days was not significant; further research is warranted.
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Affiliation(s)
- Wenmiao Luo
- Department of Neurosurgery, Susong Hospital, Xiamen, China; Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yonggang Xu
- Department of Neurosurgery, Susong Hospital, Xiamen, China
| | - Chao Liu
- Department of Neurosurgery, Susong Hospital, Xiamen, China
| | - Hengzhu Zhang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China.
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Althobaiti F, Alkhatib A, Alharbi N, Alwadai M, Alqarni A, Allebdi K. A Rare Case of Contralateral Ischemic Stroke Recurrence Post-Reperfusion: Successful Management Through Timely Thrombectomy. Cureus 2024; 16:e54788. [PMID: 38405641 PMCID: PMC10891310 DOI: 10.7759/cureus.54788] [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] [Accepted: 02/23/2024] [Indexed: 02/27/2024] Open
Abstract
Stroke is a predominant contributor to global mortality and disability and represents a complex and heterogeneous disease characterized by diverse risk factors and clinical presentations. The likelihood of stroke patients being at risk of a second stroke within the first five years is higher, especially within the initial two weeks. The distressing prospect of experiencing recurrent stroke shortly after reperfusion therapy adds an additional layer of complexity, potentially reversing prior progress. In the present case, we describe a patient who experienced a recurrent stroke within 24 hours, affecting the contralateral middle cerebral artery (MCA). This recurrence occurred after the individual underwent thrombolysis therapy for the initial stroke, emphasizing the intricate challenges associated with managing such cases and the imperative for targeted interventions to mitigate further risks and enhance patient outcomes.
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Affiliation(s)
| | | | - Naif Alharbi
- Neurology, King Fahad General Hospital, Jeddah, SAU
| | | | - Ali Alqarni
- Medicine and Surgery, University of Jeddah, Jeddah, SAU
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7
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van der Maten G, Meijs MFL, Timmer JR, Brouwers PJAM, von Birgelen C, Coutinho JM, Bouma BJ, Kerkhoff H, Helming AM, van Tuijl JH, van der Meer NA, Saxena R, Ebink C, van der Palen J, den Hertog HM. Routine transthoracic echocardiography in ischaemic stroke or transient ischaemic attack of undetermined cause: a prospective multicentre study. Neth Heart J 2024; 32:91-98. [PMID: 37870709 PMCID: PMC10834921 DOI: 10.1007/s12471-023-01819-7] [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] [Accepted: 08/23/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND Guidelines recommend routine transthoracic echocardiography (TTE) after ischaemic stroke or transient ischaemic attack of undetermined cause; yet, only limited scientific evidence exists. Therefore, we aimed to determine in these patients the prevalence of TTE-detected major cardiac sources of embolism (CSE), which are abnormalities leading to therapeutic changes. METHODS Six Dutch hospitals conducted a prospective observational study that enrolled patients with ischaemic stroke or transient ischaemic attack of undetermined cause. Patients underwent TTE after comprehensive diagnostic evaluation on stroke units, including blood chemistry, 12-lead electrocardiogram (ECG), ≥ 24 h continuous ECG monitoring, brain imaging and cervical artery imaging. Primary outcome measure was the proportion of patients with TTE-detected major CSE. RESULTS From March 2018 to October 2020, 1084 patients, aged 66.6 ± 12.5 years, were enrolled; 456 (42.1%) patients were female and 869 (80.2%) had ischaemic stroke. TTE detected major CSE in only 11 (1.0%) patients. Ten (90.9%) of these patients also had major ECG abnormalities (previous infarction, major repolarisation abnormalities, or previously unknown left bundle branch block) that would have warranted TTE assessment regardless of stroke evaluation. Such ECG abnormalities were present in 11.1% of the total study population. A single patient (0.1%) showed a major CSE despite having no ECG abnormality. CONCLUSIONS This multicentre cross-sectional study in patients who-after workup on contemporary stroke units-were diagnosed with ischaemic stroke or transient ischaemic attack of undetermined cause found TTE-detected major CSE in only 1% of all patients. Most of these patients also had major ECG abnormalities. These findings question the value of routine TTE assessment in this clinical setting.
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Affiliation(s)
- Gerlinde van der Maten
- Department of Neurology, Medisch Spectrum Twente, Enschede, The Netherlands
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
| | - Matthijs F L Meijs
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - Jorik R Timmer
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | | | - Clemens von Birgelen
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centres, location AMC, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam University Medical Centres, location AMC, Amsterdam, The Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Anne Mijn Helming
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Julia H van Tuijl
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | | | - Ritu Saxena
- Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Corné Ebink
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Job van der Palen
- Section Cognition, Data and Education, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
- Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands
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8
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van der Maten G, Meijs MFL, van der Palen J, Brouwers PJAM, von Birgelen C, van Opstal J, den Hertog HM. Atrial fibrillation detected with outpatient cardiac rhythm monitoring in patients with ischemic stroke or TIA of undetermined cause. J Stroke Cerebrovasc Dis 2023; 32:107400. [PMID: 37801878 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107400] [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: 04/09/2023] [Revised: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 10/08/2023] Open
Abstract
OBJECTIVES Guidelines advise cardiac rhythm monitoring for 3 up to 30 days for detecting atrial fibrillation (AF) in patients with ischemic stroke of undetermined cause. However, the optimal monitoring duration is unknown. We aimed to determine the AF detection rate during 7-day outpatient cardiac rhythm monitoring in this patient group. METHODS Participants from a large tertiary hospital in a prospective observational study (ATTEST) underwent outpatient cardiac rhythm monitoring after a negative standard diagnostic evaluation (i.e., 12-lead electrocardiogram and in-hospital telemetry). Primary outcome was the rate of newly detected AF. RESULTS We examined 373 patients [age: 67.8±11.6 years; women: 166(44.5%); stroke: 278(74.5%)]. Median monitoring duration was 7 days (Inter Quartile Range (IQR) 7-7), performed after median of 36 days (IQR 27-47). AF was newly detected in 17(4.6%) patients, 5.4% of patients with ischemic stroke and 2.1% of patients with TIA. 53% of AF was detected on day-1, after day-3 73% of new AF was found. First AF episodes were detected up to day-7. Diabetes and increasing age were independent predictors of new AF. CONCLUSION After ischemic stroke or TIA of undetermined cause, 7-day outpatient cardiac rhythm monitoring detected new AF in 4.6%. Patients with AF had significantly more cardiovascular risk factors. Although about 50% of first AF episodes occurred during the first day of monitoring, new AF was detected up to day-7, implying that the recommended minimum of 3 days cardiac rhythm monitoring after ischemic stroke of undetermined cause is insufficient. Subsequent long-term rhythm monitoring should be considered in selected patients.
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Affiliation(s)
- Gerlinde van der Maten
- Department of Neurology, Medisch Spectrum Twente, Koningstraat 1, PO box 50 000, KA 7500, Enschede, The Netherlands; Department of Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands.
| | - Matthijs F L Meijs
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Job van der Palen
- Section Cognition, Education and Data, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands; Medical School wente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Paul J A M Brouwers
- Department of Neurology, Medisch Spectrum Twente, Koningstraat 1, PO box 50 000, KA 7500, Enschede, The Netherlands
| | - Clemens von Birgelen
- Department of Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands; Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Jurren van Opstal
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
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Saa JP, Lipson-Smith R, White M, Davis A, Yang T, Wilde J, Blackburn M, Churilov L, Bernhardt J. Stroke Inpatient Rehabilitation Environments: Aligning Building Construction and Clinical Practice Guidelines Through Care Process Mapping. Stroke 2023; 54:2946-2957. [PMID: 37846565 DOI: 10.1161/strokeaha.123.044216] [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: 06/15/2023] [Accepted: 09/01/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Stroke inpatient rehabilitation is a complex process involving stroke survivors, staff, and family utilizing a common space for a shared purpose: to optimize recovery. This complex pathway is rarely fully described. Stroke care is ideally guided by Clinical Practice Guidelines, and the rehabilitation built environment should serve to optimize care delivery, patient and staff experience. We aimed to articulate the inpatient stroke rehabilitation process of care in a series of process maps, and to understand the degree to which current stroke clinical and building construction (ie, design) guidelines align to support inpatient stroke rehabilitation. METHODS We used the Value-Focused Process Engineering methodology to create maps describing the events and activities that typically occur in the current stroke inpatient rehabilitation service model. These maps were completed through individual and group session consultations with stroke survivors, architects, policy makers, and clinical experts. We then determined which sections of the Australian Stroke Rehabilitation Guidelines and the Australasian Health Facility Design Guidelines could be aligned and applied to the process maps. RESULTS We present a summary process map for stroke inpatient rehabilitation, alongside detailed process maps for 4 different phases of rehabilitation (admission, a normal weekday, a weekend day, and discharge) using Value-Focused Process Engineering notation. The integration of design and clinical guidelines with care pathway maps revealed where guidelines lack detail to be readily linked to current stroke inpatient care practice, providing an opportunity to design stroke inpatient rehabilitation spaces based on the activities occurring within them. CONCLUSIONS Our findings highlight gaps where clinical and design experts should work together to use guidelines to their full potential; and to improve the process of planning for future stroke rehabilitation units.
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Affiliation(s)
- Juan Pablo Saa
- The Florey Institute (Austin Site), University of Melbourne, VIC, Australia (J.P.S., R.L.-S., J.B.)
- La Trobe University, Bundoora Campus, Melbourne, VIC, Australia (J.P.S.)
| | - Ruby Lipson-Smith
- The Florey Institute (Austin Site), University of Melbourne, VIC, Australia (J.P.S., R.L.-S., J.B.)
- The MARCS Institute for Brain, Behaviour, and Development, Western Sydney University, Penrith, NSW, Australia (R.L.-S.)
| | - Marcus White
- Swinburne University of Technology, School of Design and Architecture, Melbourne, VIC, Australia (M.W., T.Y.)
| | - Aaron Davis
- University of South Australia, Adelaide, SA, Australia (A.D., J.W.)
| | - Tianyi Yang
- Swinburne University of Technology, School of Design and Architecture, Melbourne, VIC, Australia (M.W., T.Y.)
| | - Jack Wilde
- University of South Australia, Adelaide, SA, Australia (A.D., J.W.)
| | - Marnie Blackburn
- Australasian Health Facility Guidelines, Health Infrastructure/Australasian Health Infrastructure Alliance, New South Wales Health Infrastructure, NSW, Australia (M.B.)
| | - Leonid Churilov
- The University of Melbourne, Melbourne Medical School, VIC, Australia (L.C.)
| | - Julie Bernhardt
- La Trobe University, Bundoora Campus, Melbourne, VIC, Australia (J.P.S.)
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Maciel Barbosa P, Firmino-Machado J, Ferreira LN, Tedim Cruz V, Szrek H. From healthcare system to individuals through stroke rehabilitation pathways.Outcomes, information, and satisfaction along 12 months prospective cohort in Portugal. Top Stroke Rehabil 2023; 30:727-737. [PMID: 36651648 DOI: 10.1080/10749357.2023.2165266] [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: 08/11/2022] [Accepted: 01/02/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND The nature and quality of stroke survivor rehabilitation varies throughout Europe, including in Portugal, having not been widely monitored or benchmarked. OBJECTIVES This study analyses the stroke care pathway from three perspectives: healthcare system, process, and patient. METHODS The study uses data from a one-year single-center prospective cohort of first stroke patients, assessed at baseline, 3, 6, and 12 months. Care pathways and settings were described in terms of organizational model, funding, patient involvement, frequency and intensity and multidisciplinary team. Patient-level information and satisfaction were evaluated using a 10-point numeric rating scale. Kruskal - Wallis and post-hoc tests were used to compare EQ-5D-3 L, National Institute of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), Barthel Index, Mini-Mental State Examination scores between pathways and settings. RESULTS A total of 391 acute stroke patients, with a mean disability of 3.7 (mRS) and severity of 11.7 (NIHSS) participated. Six pathways and eight settings were described. A lack of compliance between guidelines and care was identified. There were significant differences in the four outcomes between the six pathways (p-values 0.007 to 0.020) suggesting inefficiency and inequalities, with an inadequate level of information and patient satisfaction. After post-hoc analysis, pathways 1 and 2 showed highest outcomes (p-values 0.001 to 0.002). Within settings, short-term units showed high scores, followed by rehabilitation center, outpatient hospital, and community clinic (p-values 0.001 to 0.040). CONCLUSION A multilevel characterization of the post-stroke rehabilitation pathway showed a more complete perspective on stroke management which may contribute to future rehabilitation and stroke policies.
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Affiliation(s)
- Pedro Maciel Barbosa
- Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Hospital Pedro Hispano, Unidade Local de Saúde, EPE, Portugal
- Centro de Investigação em Reabilitação, Escola Superior de Saúde, Politécnico do Porto, Portugal
| | - João Firmino-Machado
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Centro Académico Clínico Egas Moniz, Aveiro, Portugal
- Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Lara Noronha Ferreira
- Universidade do Algarve - ESGHT, Portugal
- Centre for Health Studies and Research of the University of Coimbra/Centre for Innovative Biomedicine and Biotechnology, Portugal
- Research Centre for Tourism, Portugal
| | - Vitor Tedim Cruz
- Hospital Pedro Hispano, Unidade Local de Saúde, EPE, Portugal
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Helena Szrek
- Centre for Economics and Finance, University of Porto, Porto, Portugal
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Lind A, Ahsan M, Totzeck M, Al-Rashid F, Haddad A, Dubler S, Brenner T, Skarabis A, El Gabry M, Rassaf T, Jánosi RA. Virtual reality-assisted distraction during transcatheter aortic valve implantation under local anaesthesia: A randomised study. Int J Cardiol 2023; 387:131130. [PMID: 37355243 DOI: 10.1016/j.ijcard.2023.131130] [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] [Received: 05/17/2023] [Revised: 06/05/2023] [Accepted: 06/20/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND A minimal approach, using local anaesthesia alone, has been advocated to promote faster transcatheter aortic valve replacement (TAVR) procedures in intermediate-risk patients. Pre- and periprocedural anxiety and pain remain a concern. Virtual reality (VR) is a form of non-pharmacological distraction that can potentially modulate pain and anxiety. This randomised study explored whether VR reduces pain and anxiety during TAVR without sedation and compared the effects of VR with those of standard care. METHODS AND RESULTS Between June 2022 and March 2023, 207 patients underwent transfemoral TAVR (TF-TAVR). Of these, 117 (56.5%) patients were willing to participate in the study and met the educational background and mental status criteria for assessment. Fifty-nine patients underwent TF-TAVR with VR glasses (VR group). Fifty-eight patients underwent standard TF-TAVR without VR (control group; CG). Post-interventional anxiety scores (STAI-S) (31.5 ± 13.4 vs. 38.5 ± 19.2, p = 0.02) and the perceived duration of the procedure (60.1 ± 32.3 vs. 73.0 ± 32.4, p = 0.04) were lower in the VR than in the CG. Procedure time, pain, and anxiety scores (visual analogue scale) were similar between the groups. The complication rate was low and not associated with VR. Post-interventional delirium occurred in nine patients, and was similar between the groups (VR: 4 [6.8%] vs. CG: 5 [8.6%], p = 0.71). No periprocedural strokes were observed. CONCLUSION VR for TAVR is feasible and safe and expands the non-drug spectrum of therapy for anxiety and pain in patients undergoing TAVR with a minimalistic approach.
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Affiliation(s)
- Alexander Lind
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
| | - Majid Ahsan
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Fadi Al-Rashid
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ali Haddad
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Simon Dubler
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Thorsten Brenner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Annabell Skarabis
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Mohamed El Gabry
- Department of Heart Surgery, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Rolf Alexander Jánosi
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Hindsholm MF, Damgaard D, Gurol ME, Gaist D, Simonsen CZ. Management and Prognosis of Acute Stroke in Atrial Fibrillation. J Clin Med 2023; 12:5752. [PMID: 37685819 PMCID: PMC10489015 DOI: 10.3390/jcm12175752] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/25/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
Atrial fibrillation (AF) is an important risk factor for ischemic stroke (IS). Oral anticoagulation (OAC) significantly reduces the risk of IS in AF but also increases the risk of systemic bleeding, including intracerebral hemorrhage (ICH). AF-related strokes are associated with greater disability and mortality compared to non-AF strokes. The management of patients with AF-related strokes is challenging, and it involves weighing individual risks and benefits in the acute treatment and preventive strategies of these patients. This review summarizes the current knowledge of the acute management of ischemic and hemorrhagic stroke in patients with AF, and the prognosis and potential implications for management both in the acute and long-term setting.
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Affiliation(s)
- Mette F. Hindsholm
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus, Denmark; (D.D.); (C.Z.S.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus, Denmark; (D.D.); (C.Z.S.)
| | - M. Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA;
- Harvard Medical School, Boston, MA 02115, USA
| | - David Gaist
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, 5000 Odense, Denmark;
| | - Claus Z. Simonsen
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus, Denmark; (D.D.); (C.Z.S.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
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13
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Farjat-Pasos JI, Chamorro A, Lanthier S, Robichaud M, Mengi S, Houde C, Rodés-Cabau J. Cerebrovascular Events in Older Patients With Patent Foramen Ovale: Current Status and Future Perspectives. J Stroke 2023; 25:338-349. [PMID: 37813671 PMCID: PMC10574307 DOI: 10.5853/jos.2023.01599] [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: 05/15/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 10/11/2023] Open
Abstract
Patent foramen ovale (PFO) closure, along with medical therapy, has emerged as the therapeutic gold standard in younger (<60-year-old) patients with a PFO-related stroke for preventing recurrent events. However, PFO management guidelines lack definite recommendations for older (>60 years) patients with a PFO-related cerebrovascular event, a complex group of patients who were mostly excluded from PFO closure clinical trials. Nevertheless, several studies have shown a higher prevalence of PFO among older patients with cryptogenic stroke, and its presence has been associated with an increased risk of recurrent events. Furthermore, older patients exhibit a higher prevalence of high-risk PFO anatomical features, present inherent age-related risk factors that might increase the risk of paradoxical embolism through a PFO, and have a higher incidence of ischemic events after a PFO-related event. Additionally, observational studies have shown the safety and preliminary efficacy of PFO closure in older PFO-related stroke patients. Yet, higher rates of recurrent cerebrovascular events and new-onset atrial fibrillation were observed in some studies among older patients compared to their younger counterparts. After careful case-by-case evaluation, including the assessment of hidden potential cardioembolic sources of a cryptogenic stroke other than PFO, transcatheter PFO closure might be a safe and effective therapeutic option for preventing recurrent thromboembolic events in patients >60 years with a high-risk PFO-associated stroke. Ongoing trials will provide important insights into the role of PFO closure in the elderly population.
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Affiliation(s)
- Julio I. Farjat-Pasos
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
| | - Angel Chamorro
- Department of Neuroscience, Hospital Clinic, University of Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Sylvain Lanthier
- Neurovascular Program and Research Center, Montreal Sacre Coeur Hospital; Montreal, Canada
| | - Mathieu Robichaud
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
| | - Siddhartha Mengi
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
| | - Christine Houde
- Department of Pediatric Cardiology, Laval University Hospital Center, Quebec City, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
- Department of Research & Innovation, Clínic Barcelona, Barcelona, Spain
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14
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Schlemm L, Siebert E, Kleine JF, Riegler C, Bode FJ, Petersens M, Schlemm E, Keil F, Tiedt S, Bohner G, Nolte CH. Decline of thrombolysis rates before endovascular therapy in patients with acute anterior circulation large vessel occlusion ischemic stroke: A multicenter analysis from the German Stroke Registry. Eur Stroke J 2023; 8:610-617. [PMID: 37243508 PMCID: PMC10472953 DOI: 10.1177/23969873231177774] [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: 03/30/2023] [Accepted: 05/07/2023] [Indexed: 05/29/2023] Open
Abstract
INTRODUCTION In recent years, the role of intravenous thrombolysis (IVT) before endovascular stroke treatment (EVT) has been discussed intensively. Whether the discussion was accompanied by changing rates of bridging IVT is unknown. METHODS Data were extracted from the prospectively maintained German Stroke Registry, including patients treated with EVT at one of 28 stroke centers in Germany between 2016 and 2021. Primary outcome parameters were the rate of bridging IVT (a) in the entire registry cohort and (b) in patients without formal contraindications to IVT (i.e. recent oral anticoagulants, time window ⩾4.5 h, extensive early ischemic changes) adjusted for demographic and clinical confounders. RESULTS 10,162 patients (52.8% women, median age 77 years, median National Institutes of Health Stroke Scale score 14) were analyzed. In the entire cohort, the rate of bridging IVT decreased from 63.8% in 2016 to 43.6% in 2021 (average absolute annual decrease 3.1%, 95% CI 2.4%-3.8%), while the proportion of patients with at least one formal contraindication increased by only 1.2% annually (95% CI 0.6%-1.9%). Among 5460 patients without record of formal contraindications, the rate of bridging IVT decreased from 75.5% in 2016 to 63.2% in 2021 and was significantly associated with admission date in a multivariable model (average absolute annual decrease 1.4%, 95% CI 0.6%-2.2%). Clinical factors associated with lower odds of bridging IVT included diabetes mellitus, carotid-T-occlusion, dual antiplatelet therapy, and direct admission to a thrombectomy center. CONCLUSION We observed a substantial decline in bridging IVT rates independent of demographic confounders and not explained by an increase in contraindications. This observation deserves further exploration in independent populations.
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Affiliation(s)
- Ludwig Schlemm
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Radiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Justus F Kleine
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Riegler
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Felix J Bode
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Fee Keil
- Institute for Neuroradiology, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Georg Bohner
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
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15
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Leentjens J, Chornenki NLJ, Spiegelenberg J, Ly V, Dowlatshahi D, Siegal DM. A scoping review protocol on diagnostic strategies to detect occult malignancies in individuals with ischemic stroke. PLoS One 2023; 18:e0289048. [PMID: 37478139 PMCID: PMC10361530 DOI: 10.1371/journal.pone.0289048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 07/05/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Emerging data show an increased risk of ischemic stroke in patients with a new diagnosis of cancer. As the risk of stroke begins to increase 150 days before cancer is diagnosed, stroke may be the first clinical manifestation of undiagnosed cancer. About 6% of patients with cryptogenic ischemic stroke (unknown etiology after diagnostic evaluations) are diagnosed with cancer within one year. However, the optimal cancer screening strategy in this population is not known. We aim to conduct a scoping review of screening strategies for occult cancer in individuals with ischemic stroke. METHODS Electronic databases including MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCOhost) and Scopus will be systematically searched to identify articles that report on screening strategies for occult cancer in individuals with ischemic stroke. At least two investigators will independently perform two-stage study selection consisting of title/abstract screening and full-text review, followed by data extraction. Thereafter, a thematic analysis will be conducted to provide an overview of what diagnostic tests/strategies have been used, and their clinical utility in terms of positive and negative predictive value (when available). CONCLUSION We anticipate that the findings of this scoping review will identify strategies used to detect occult cancer in individuals with ischemic stroke and summarize their clinical utility (if reported). Addressing this knowledge gap will help guide the development of future clinical trials on occult cancer screening patients with ischemic stroke.
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Affiliation(s)
- Jenneke Leentjens
- Department of Internal Medicine & Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Janneke Spiegelenberg
- Department of Internal Medicine & Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Synapse Research Institute, Maastricht, The Netherlands
| | - Valentina Ly
- Health Sciences Library, University of Ottawa, Ottawa, Canada
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Korostovtseva L, Bochkarev M, Amelina V, Nikishkina U, Osipenko S, Vasilieva A, Zheleznyakov V, Zabroda E, Gordeev A, Golovkova-Kucheryavaia M, Yanishevskiy S, Sviryaev Y, Konradi A. Sleep-Disordered Breathing and Prognosis after Ischemic Stroke: It Is Not Apnea-Hypopnea Index That Matters. Diagnostics (Basel) 2023; 13:2246. [PMID: 37443640 DOI: 10.3390/diagnostics13132246] [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: 05/08/2023] [Revised: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Sleep-disordered breathing (SDB) is highly prevalent after stroke and is considered to be a risk factor for poor post-stroke outcomes. The aim of this observational study was to evaluate the effect of nocturnal respiratory-related indices based on nocturnal respiratory polygraphy on clinical outcomes (including mortality and non-fatal events) in patients with ischemic stroke. METHODS A total of 328 consecutive patients (181 (55%) males, mean age 65.8 ± 11.2 years old) with confirmed ischemic stroke admitted to a stroke unit within 24 h after stroke onset were included in the analysis. All patients underwent standard diagnostic and treatment procedures, and sleep polygraphy was performed within the clinical routine in the first 72 h after admission. The long-term outcomes were assessed by cumulative endpoint (death of any cause, new non-fatal myocardial infarction, new non-fatal stroke/transient ischemic attack, emergency revascularization, emergency hospitalization due to the worsening of cardiovascular disease). A Cox-regression analysis was applied to evaluate the effects of nocturnal respiratory indices on survival. RESULTS The mean follow-up period comprised 12 months (maximal-48 months). Patients with unfavourable outcomes demonstrated a higher obstructive apnea-hypopnea index, a higher hypoxemia burden assessed as a percent of the time with SpO2 < 90%, a higher average desaturation drop, and a higher respiratory rate at night. Survival time was significantly lower (30.6 (26.5; 34.7) versus 37.9 (34.2; 41.6) months (Log Rank 6.857, p = 0.009)) in patients with higher hypoxemia burden (SpO2 < 90% during ≥2.1% versus <2.1% of total analyzed time). However, survival time did not differ depending on the SDB presence assessed by AHI thresholds (either ≥5 or ≥15/h). The multivariable Cox proportional hazards regression (backward stepwise analysis) model demonstrated that the parameters of hypoxemia burden were significantly associated with survival time, independent of age, stroke severity, stroke-related medical interventions, comorbidities, and laboratory tests. CONCLUSION Our study demonstrates that the indices of hypoxemia burden have additional independent predictive value for long-term outcomes (mortality and non-fatal cardiovascular events) after ischemic stroke.
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Affiliation(s)
| | - Mikhail Bochkarev
- Almazov National Medical Research Centre, 197341 St. Petersburg, Russia
| | - Valeria Amelina
- Almazov National Medical Research Centre, 197341 St. Petersburg, Russia
- Department of Clinical Psychology, Herzen State Pedagogical University, 191186 St. Petersburg, Russia
| | | | - Sofia Osipenko
- Almazov National Medical Research Centre, 197341 St. Petersburg, Russia
- Medical Faculty, Pavlov University, 197022 St. Petersburg, Russia
| | | | | | - Ekaterina Zabroda
- Almazov National Medical Research Centre, 197341 St. Petersburg, Russia
- Biology Faculty, Saint Petersburg State University, 199034 St. Petersburg, Russia
| | - Alexey Gordeev
- Almazov National Medical Research Centre, 197341 St. Petersburg, Russia
- Biology Faculty, Saint Petersburg State University, 199034 St. Petersburg, Russia
| | | | | | - Yurii Sviryaev
- Almazov National Medical Research Centre, 197341 St. Petersburg, Russia
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Lam MSH, Luoma AMV, Reddy U. Acute perioperative neurological emergencies. Int Anesthesiol Clin 2023; 61:53-63. [PMID: 37249171 DOI: 10.1097/aia.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Michelle S H Lam
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Astri M V Luoma
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
| | - Ugan Reddy
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
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18
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Lucà F, Colivicchi F, Oliva F, Abrignani M, Caretta G, Di Fusco SA, Giubilato S, Cornara S, Di Nora C, Pozzi A, Di Matteo I, Pilleri A, Rao CM, Parlavecchio A, Ceravolo R, Benedetto FA, Rossini R, Calvanese R, Gelsomino S, Riccio C, Gulizia MM. Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation. Front Cardiovasc Med 2023; 10:1061618. [PMID: 37304967 PMCID: PMC10249073 DOI: 10.3389/fcvm.2023.1061618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 04/14/2023] [Indexed: 06/13/2023] Open
Abstract
Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Furio Colivicchi
- Cardiology Division, San Filippo Neri Hospital, ASL Roma 1, Roma, Italy
| | - Fabrizio Oliva
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | | | - Giorgio Caretta
- Cardiology Unit, Sant'Andrea Hospital, ASL 5 Liguria, La Spezia, Italy
| | | | | | - Stefano Cornara
- Cardiology Division San Paolo Hospital, ASL 2, Savona, Italy
| | | | - Andrea Pozzi
- Cardiology Division, Maria della Misericordia di Udine, Italy
| | - Irene Di Matteo
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | - Anna Pilleri
- Cardiology Division, Brotzu Hospital, Cagliari, Italy
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Antonio Parlavecchio
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Roberto Ceravolo
- Cardiology Division, Giovanni Paolo II Hospital, Lamezia Terme, Italy
| | - Francesco Antonio Benedetto
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | | | | | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University, Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, A.O.R.N. Sant'Anna e San Sebastiano, Caserta, Italy
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Richards CT, Oostema JA, Chapman SN, Mamer LE, Brandler ES, Alexandrov AW, Czap AL, Martinez-Gutierrez JC, Martin-Gill C, Panchal AR, McMullan JT, Zachrison KS. Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners. Stroke 2023; 54:1416-1425. [PMID: 36866672 PMCID: PMC10133016 DOI: 10.1161/strokeaha.123.039792] [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: 01/03/2023] [Accepted: 02/02/2023] [Indexed: 03/04/2023]
Abstract
The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.
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Affiliation(s)
- Christopher T. Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - J. Adam Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI
| | | | - Lauren E. Mamer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Ethan S. Brandler
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Anne W. Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis, TN
| | - Alexandra L. Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | | | | | - Ashish R. Panchal
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jason T. McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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20
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Fifi JT, Yaeger K, Matsoukas S, Hassan AE, Yoo A, Sheth S, Zaidat OO. Aspiration thrombectomy of M2 middle cerebral artery occlusion to treat acute ischemic stroke: A core lab–adjudicated subset analysis from the COMPLETE registry and literature review. Front Neurol 2023; 14:1076754. [PMID: 37064191 PMCID: PMC10100586 DOI: 10.3389/fneur.2023.1076754] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/06/2023] [Indexed: 04/03/2023] Open
Abstract
BackgroundAlthough the benefits of aspiration thrombectomy for treating acute ischemic stroke caused by proximal large vessel occlusion have been established, fewer data are available for evaluating aspiration thrombectomy of distal occlusion. The objective of this study was to evaluate, by means of prospectively collected data, the safety and efficacy of aspiration thrombectomy in patients with M2 middle cerebral artery (MCA) occlusion.MethodsThis study is a subset analysis of a global prospective multicenter observational registry that included patients who presented with either anterior or posterior large vessel occlusion and were eligible for mechanical thrombectomy using the Penumbra System including the Penumbra 3D Revascularization Device. For this analysis, all patients in the registry with M2 MCA occlusion were included.ResultsOf the 650 patients in the registry, 113 (17.4%) had M2 MCA occlusion. The rate of a modified treatment in cerebral infarction score of 2b to 3 after the procedure was 79.6% (90/113), the rate of a modified Rankin Scale score of 0–2 at 90 days was 72.5% (79/109), and the all-cause mortality rate at 90 days was 8.8% (10/113). Device-related serious adverse events occurred in one patient (0.9%) within 24 h and in two patients (1.8%) overall. Procedure-related serious adverse events occurred in four patients (3.5%) within 24 h and in six patients (5.3%) overall (nine events).ConclusionFor appropriately selected patients, aspiration thrombectomy for acute ischemic stroke due to M2 MCA occlusion was safe and effective, with high rates of technical success and good functional outcome.
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Affiliation(s)
- Johanna T. Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- *Correspondence: Johanna T. Fifi
| | - Kurt Yaeger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Stavros Matsoukas
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ameer E. Hassan
- Valley Baptist Medical Center, Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX, United States
| | - Albert Yoo
- Texas Stroke Institute, Dallas, TX, United States
| | - Sunil Sheth
- UTHealth McGovern Medical School, Houston, TX, United States
| | - Osama O. Zaidat
- Department of Endovascular Neurosurgery, Mercy Health St. Vincent Medical Center, Toledo, OH, United States
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21
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Immigration Status as a Social Determinant of Stroke Care. Med Care 2023; 61:117-119. [PMID: 36662628 DOI: 10.1097/mlr.0000000000001821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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22
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Martin-Gill C, Brown KM, Cash RE, Haupt RM, Potts BT, Richards CT, Patterson PD. 2022 Systematic Review of Evidence-Based Guidelines for Prehospital Care. PREHOSP EMERG CARE 2023; 27:131-143. [PMID: 36369826 DOI: 10.1080/10903127.2022.2143603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Multiple national organizations and federal agencies have promoted the development, implementation, and evaluation of evidence-based guidelines (EBGs) for prehospital care. Previous efforts have identified opportunities to improve the quality of prehospital guidelines and highlighted the value of high-quality EBGs to inform initial certification and continued competency activities for EMS personnel. OBJECTIVES We aimed to perform a systematic review of prehospital guidelines published from January 2018 to April 2021, evaluate guideline quality, and identify top-scoring guidelines to facilitate dissemination and educational activities for EMS personnel. METHODS We searched the literature in Ovid Medline and EMBASE from January 2018 to April 2021, excluding guidelines identified in a prior systematic review. Publications were retained if they were relevant to prehospital care, based on organized reviews of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised to identify if they met the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored across the six domains of the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS We identified 75 guidelines addressing a variety of clinical and operational aspects of EMS medicine. About half (n = 39, 52%) addressed time/life-critical conditions and 33 (44%) contained recommendations relevant to non-clinical/operational topics. Fewer than half (n = 35, 47%) were based on systematic reviews of the literature. Nearly one-third (n = 24, 32%) met all NAM criteria for clinical practice guidelines. Only 27 (38%) guidelines scored an average of >75% across AGREE II domains, with content relevant to guideline implementation most commonly missing. CONCLUSIONS This interval systematic review of prehospital EBGs identified many new guidelines relevant to prehospital care; more than all guidelines reported in a prior systematic review. Our review reveals important gaps in the quality of guideline development and the content in their publications, evidenced by the low proportion of guidelines meeting NAM criteria and the scores across AGREE II domains. Efforts to increase guideline dissemination, implementation, and related education may be best focused around the highest quality guidelines identified in this review.
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Affiliation(s)
- Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kathleen M Brown
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachel M Haupt
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Benjamin T Potts
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - P Daniel Patterson
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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23
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Rizos T, Jenetzky E, Nabavi DG, Haeusler KG, Wachter R, Ossenbrink M, Ringleb PA, Busse O. Echocardiography in acute stroke patients: a nationwide analysis in departments with certified stroke units in Germany. Neurol Res Pract 2023; 5:3. [PMID: 36653887 PMCID: PMC9850591 DOI: 10.1186/s42466-022-00229-1] [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: 11/11/2022] [Accepted: 12/19/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Echocardiography is highly relevant in patients with ischemic stroke or TIA. Utilization of routine echocardiographic examinations [transthoracic (TTE) or transesophageal (TEE)] on stroke units remains however unknown. To representatively examine echocardiographic rates on stroke units in Germany and to evaluate structural factors that may influence the decision to conduct echocardiography. METHODS A nationwide analysis was performed by using certification audit data of all primary and comprehensive stroke centers (pSC and cSC) in Germany. RESULTS Structural and organizational requirements of 310 departments (cSCs: 42.6%) were extracted. Median TTE rate was 63.3% (IQR 39.3-80.8), median TEE rate 21.3% (IQR 16.4-29.5). A cardiological department on site was present in 74.2%, and they were associated with higher TEE rates. TTE rates decreased with increasing numbers of patients (p = 0.026). Likewise, TEE rates decreased with increasing numbers of patients (p = 0.006), mediated by departments with cSCs (p = 0.008 for cSCs vs p = 0.230 for pSCs). TTE rates were far more inhomogeneously distributed than TEE rates and higher in pSCs (p = 0.011). Overall, 12.9% of centers did not perform any echocardiographic examination in at least 50% of all stroke patients. CONCLUSION More detailed recommendations regarding echocardiography should be included in future guidelines. Moreover, evaluating the impact of echocardiographic examinations on long-term prognosis in stroke patients should be focus of further evaluations.
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Affiliation(s)
- Timolaos Rizos
- grid.7700.00000 0001 2190 4373Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Ekkehart Jenetzky
- grid.412581.b0000 0000 9024 6397Faculty of Health/School of Medicine, Witten/Herdecke University, Witten, Germany ,grid.5802.f0000 0001 1941 7111Department for Child and Adolescent Psychiatry, Johannes Gutenberg-University, Mainz, Germany
| | - Darius Günther Nabavi
- grid.433867.d0000 0004 0476 8412Department of Neurology, Vivantes Klinikum Neukölln, Rudower Str 48, 12351 Berlin, Germany
| | - Karl Georg Haeusler
- grid.8379.50000 0001 1958 8658Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Rolf Wachter
- grid.411339.d0000 0000 8517 9062Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Martin Ossenbrink
- grid.469884.f0000 0001 2034 2604LGA InterCert GmbH, Nuremberg, Germany
| | - Peter Arthur Ringleb
- grid.7700.00000 0001 2190 4373Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Otto Busse
- Deutsche Schlaganfall Gesellschaft, Berlin, Germany
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Post-Stroke Rehabilitation: Challenges and New Perspectives. J Clin Med 2023; 12:jcm12020550. [PMID: 36675486 PMCID: PMC9867345 DOI: 10.3390/jcm12020550] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 01/04/2023] [Indexed: 01/12/2023] Open
Abstract
A stroke is determined by insufficient blood supply to the brain due to vessel occlusion (ischemic stroke) or rupture (hemorrhagic stroke), resulting in immediate neurological impairment to differing degrees [...].
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25
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Periprocedure Management of Blood Pressure After Acute Ischemic Stroke. J Neurosurg Anesthesiol 2023; 35:4-9. [PMID: 36441847 DOI: 10.1097/ana.0000000000000891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 11/30/2022]
Abstract
The management of acute ischemic stroke primarily revolves around the timely restoration of blood flow (recanalization/reperfusion) in the occluded vessel and maintenance of cerebral perfusion through collaterals before reperfusion. Mechanical thrombectomy is the most effective treatment for acute ischemic stroke due to large vessel occlusions in appropriately selected patients. Judicious management of blood pressure before, during, and after mechanical thrombectomy is critical to ensure good outcomes by preventing progression of cerebral ischemia as well hemorrhagic conversion, in addition to optimizing systemic perfusion. While direct evidence to support specific hemodynamic targets around mechanical thrombectomy is limited, there is increasing interest in this area. Newer approaches to blood pressure management utilizing individualized cerebral autoregulation-based targets are being explored. Early efforts at utilizing machine learning to predict blood pressure treatment thresholds and therapies also seem promising; this focused review aims to provide an update on recent evidence around periprocedural blood pressure management after acute ischemic stroke, highlighting its implications for clinical practice while identifying gaps in current literature.
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26
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Forfang E, Larsen KT, Salman RA, Bell SM, Wester P, Berge E, Wyller TB, Rønning OM. Antithrombotic treatment after intracerebral hemorrhage: Surveys among stroke physicians in Scandinavia and the United Kingdom. Health Sci Rep 2023; 6:e1059. [PMID: 36698713 PMCID: PMC9854165 DOI: 10.1002/hsr2.1059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/09/2022] [Accepted: 01/03/2023] [Indexed: 01/21/2023] Open
Abstract
Background and Aims It is unclear whether patients with previous intracerebral hemorrhage (ICH) should receive antithrombotic treatment to prevent ischemic events. We assessed stroke physicians' opinions about this, and their views on randomizing patients in trials assessing this question. Methods We conducted three web-based surveys among stroke physicians in Scandinavia and the United Kingdom. Results Eighty-nine of 205 stroke physicians (43%) responded to the Scandinavian survey, 161 of 180 (89%) to the UK antiplatelet survey, and 153 of 289 (53%) to the UK anticoagulant survey. In Scandinavia, 19 (21%) stroke physicians were uncertain about antiplatelet treatment after ICH for ischemic stroke or transient ischemic attack (TIA) and 21 (24%) for prior myocardial infarction. In the United Kingdom, 116 (77%) were uncertain for ischemic stroke or TIA and 115 (717%) for ischemic heart disease. In Scandinavia, 32 (36%) were uncertain about anticoagulant treatment after ICH for atrial fibrillation, and 26 (29%) for recurrent deep vein thrombosis or pulmonary embolism. In the United Kingdom, 145 (95%) were uncertain about anticoagulants after ICH in at least some cases. In both regions combined, 191 of 250 (76%) would consider randomizing ICH survivors in a trial of starting versus avoiding antiplatelets, and 176 of 242 (73%) in a trial of starting versus avoiding anticoagulants. Conclusion Considerable proportions of stroke physicians in Scandinavia and the United Kingdom were uncertain about antithrombotic treatment after ICH. A clear majority would consider randomizing patients in trials assessing this question. These findings support the need for such trials.
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Affiliation(s)
- Elisabeth Forfang
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of Geriatric MedicineOslo University HospitalOsloNorway
| | - Kristin Tveitan Larsen
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of Geriatric MedicineOslo University HospitalOsloNorway
| | | | - Simon M. Bell
- Sheffield Institute for Translational NeuroscienceUniversity of SheffieldSheffieldUK
| | - Per Wester
- Department of Public Health and Clinical ScienceUniversity of UmeåUmeåSweden
- Department of Clinical ScienceKarolinska Institutet Danderyds HospitalStockholmSweden
| | - Eivind Berge
- Department of CardiologyOslo University HospitalOsloNorway
| | - Torgeir Bruun Wyller
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of Geriatric MedicineOslo University HospitalOsloNorway
| | - Ole Morten Rønning
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of NeurologyAkershus University HospitalNordbyhagenNorway
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27
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Kolokathis K, Thomopoulos C, Tsioufis K. Net clinical benefit of PFO closure versus medical treatment in patients with cryptogenic stroke: A systematic review and meta-analysis. Hellenic J Cardiol 2022; 70:46-52. [PMID: 36584788 DOI: 10.1016/j.hjc.2022.12.010] [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: 07/15/2022] [Revised: 12/02/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The ideal treatment for patent foramen ovale (PFO) in patients with cryptogenic stroke remains controversial and is being evaluated. The objective of this study was to evaluate the net clinical benefit (NCB) between PFO closure and medical treatment. METHODS We searched three electronic databases from inception until January 2022. The primary outcomes were the NCB-1, defined as the cumulative incidence of stroke, major bleeding, atrial fibrillation/flutter, and serious procedural or device complications; the NCB-2 and NCB-3 were defined as NCB1 but using a weighted factor of 0.5 and 0.25 for atrial fibrillation/flutter events, respectively. We also evaluated each component outcome of NCB as a secondary outcome. Risk ratios (RR) and 95% confidence intervals (CI) of each outcome were calculated (random-effects model). RESULTS Our analysis included six RCTs (n = 3750 patients). The rates of NCB-1, NCB-2, and NCB-3 were not different between PFO closure and medical treatment. The heterogeneity between trials was low to moderate. Stroke showed a significant relative decrease of 44% (95% CI, 21-60%), favoring the PFO closure arm. Atrial fibrillation/flutter increased by 4.04 times (95% CI, 1.57-8.89) in the PFO closure compared with the medical treatment group. In a meta-regression analysis, the reduction in NCB-1 with PFO closure increased as the proportion of patients treated with the Amplatzer device increased (p = 0.02), and the reduction in NCB-1, NCB-2, and NCB-3 with PFO closure increased as the proportion of patients treated with substantial PFO size increased (p = 0.03). CONCLUSION The NCB between PFO closure and medical treatment was not different, suggesting individualized treatment to maximize benefit.
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Affiliation(s)
- Konstantinos Kolokathis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | | | - Konstantinos Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece.
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Himmelreich JCL, Lucassen WAM, Coutinho JM, Harskamp RE, de Groot JR, CPM van Weert H. 14-day Holter monitoring for atrial fibrillation after ischemic stroke: The yield of guideline-recommended monitoring duration. Eur Stroke J 2022; 8:157-167. [PMID: 37021150 PMCID: PMC10069211 DOI: 10.1177/23969873221146027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/29/2022] [Indexed: 12/25/2022] Open
Abstract
Introduction: Current European Stroke Organisation (ESO) guidelines recommend >48 h of continuous electrocardiographic monitoring for atrial fibrillation (AF) in all patients with ischemic stroke or transient ischemic attack (TIA) with undetermined origin. We assessed the yield of the guideline-recommended monitoring for AF, as well as of extending monitoring up to 14 days. Patients and methods: We included consecutive patients with stroke/TIA without AF in an academic hospital in The Netherlands. We reported AF incidence and number needed to screen (NNS) in the overall sample after 48 h and 14 days of Holter monitoring. Results: Among 379 patients with median age 63 years (IQR 55–73), 58% male, Holter monitoring detected 10 cases of incident AF during a median of 13 (IQR 12–14) days of monitoring. Seven AF cases were detected within the first 48 hours (incidence 1.85%, 95% CI 0.74–3.81; NNS 54), and three additional AF cases were recorded among the 362 patients with >48 h of monitoring and without AF ⩽ 48 h (incidence 0.83%, 95% CI: 0.17–2.42; NNS 121). All AF cases were detected within the first 7 days of monitoring. Our sample was subject to sampling bias favoring inclusion of participants with low AF risk. Discussion: Strengths of this work were the broad inclusion criteria as recommended by ESO guidelines, and high Holter adherence among participants. The analysis was limited by inclusion of lower-risk cases and a relatively small sample size. Conclusion: In low-risk patients with recent stroke or TIA, ESO guideline-recommended screening for AF resulted in a low AF yield, with limited additional value of monitoring up to 14 days. Our results underline the need for a personalized approach in determining a patient’s optimum duration for post-stroke non-invasive ambulatory monitoring.
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Affiliation(s)
- Jelle CL Himmelreich
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Personalized Medicine, Amsterdam, The Netherlands
| | - Wim AM Lucassen
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Personalized Medicine, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Ralf E Harskamp
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Personalized Medicine, Amsterdam, The Netherlands
| | - Joris R de Groot
- Department of Cardiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure & Arrhythmias, Amsterdam, The Netherlands
| | - Henk CPM van Weert
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Personalized Medicine, Amsterdam, The Netherlands
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Gogos C, Zarvalis E, Pantelidis P, Davora F, Karakanas A, Pitetzis D, Stamatiadis N, Moschovidis V, Konstantinidou M, Oikonomou E, Deretzi G, Rudolf J, Styliadis I. Excessive supraventricular ectopic activity and future onset of atrial fibrillation in patients with cryptogenic stroke. J Stroke Cerebrovasc Dis 2022; 31:106820. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022] Open
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30
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Cao W, Kadir AA, Wang J, Hu L, Wen L, Yu M, Peng L, Chen L, Luo N, Hassan II. Medication non-adherence and associated factors among older adult stroke survivors in China. Front Pharmacol 2022; 13:1054603. [PMID: 36506570 PMCID: PMC9731135 DOI: 10.3389/fphar.2022.1054603] [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: 09/27/2022] [Accepted: 11/02/2022] [Indexed: 11/25/2022] Open
Abstract
Aim: Medication non-adherence has remained a common and costly global health issue of growing importance among older adults. This study aims to determine the prevalence and associated factors related to medication non-adherence among older adult stroke survivors in China. Methods and results: In this cross-sectional study, a total of 402 older adult stroke survivors were recruited from three tertiary hospitals in China. The results of the survey showed that 61.4% exhibited medication non-adherence. The chances of medication non-adherence among older adult stroke survivors who had primary school or less educational levels were higher than those who had senior secondary and junior college educational levels [OR (95% CI) = 0.440(0.249, 0.778)] as well as those who had a bachelor's degree or above educational levels [OR (95%CI) = 0.367(0.202, 0.667)]. Moreover, the probability of medication non-adherence with 4-5 and ≥6 types of total prescription medications per day increased by 1.993 times [OR (95% CI) = 1.993(1.190, 3.339))] and 2.233 times [OR (95%CI) = 2.233(1.159, 4.300)], respectively, as compared to when there were ≤3 types. Furthermore, medication non-adherence decreased with the increase in health literacy scores (β = -0.641 (95% CI; (0.913, 0.965)) and BMQ specific-necessity scores (β = -0.131 (95% CI; 0.806, 0.995)). On the other hand, when the BMQ specific-concerns score increased by one unit, medication non-adherence increased by 11.1% [OR (95% CI) = 1.111(1.044, 1.182)]. Conclusion: The present study found that patient medication adherence among older adult stroke survivors in China is problematic and associated with educational levels, total prescribed drugs per day, beliefs about medication, and health literacy scores. This indicates that measures should be taken to enhance medication adherence among such higher-risk populations.
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Affiliation(s)
- Wenjing Cao
- School of Health Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia,Xiang Nan University, Chenzhou, Hunan, China
| | - Azidah Abdul Kadir
- School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Juan Wang
- Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
| | - Lin Hu
- Xiang Nan University, Chenzhou, Hunan, China
| | - Linlan Wen
- Chenzhou No.1 People’s Hospital, Chenzhou, Hunan, China
| | - Mei Yu
- Chenzhou Third People’s Hospital, Chenzhou, Hunan, China
| | - Liqun Peng
- Affiliated hospital of Xiangnan University, Chenzhou, Hunan, China
| | - Lanying Chen
- Affiliated hospital of Xiangnan University, Chenzhou, Hunan, China
| | - Na Luo
- Xiang Nan University, Chenzhou, Hunan, China
| | - Intan Idiana Hassan
- School of Health Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia,*Correspondence: Intan Idiana Hassan, ,
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Komarov AL, Krivosheeva EN, Makeev MI, Merkulov EV, Tripoten MI, Panchenko EP. [Patent foramen ovale as the cause of recurrent embolic strokes. Case report]. TERAPEVT ARKH 2022; 94:1109-1114. [PMID: 36286763 DOI: 10.26442/00403660.2022.09.201842] [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: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 06/16/2023]
Abstract
А clinical case of a young patient with recurrent ischemic strokes is presented. The problems of diagnostic embolic strokes are discussed. We set out the algorithm for identifying patients, in whom patent foramen ovale is the most probable cause of embolic stroke. Detailed consideration of imaging diagnostic methods possibility is included. Hypothesis of probable source of cardioembolism from patent foramen ovale is presented. Recommendations for the secondary prevention of recurrent ischemic stroke, associated with patent foramen ovale, are provided. We also considered the issues of antithrombotic treatment.
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Affiliation(s)
- A L Komarov
- Chazov National Medical Research Center of Cardiology
| | | | - M I Makeev
- Chazov National Medical Research Center of Cardiology
| | - E V Merkulov
- Chazov National Medical Research Center of Cardiology
| | - M I Tripoten
- Chazov National Medical Research Center of Cardiology
| | - E P Panchenko
- Chazov National Medical Research Center of Cardiology
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Moorthamers S, Mattar N, Frezals L, Preseau T, Gazagnes MD. Thrombolysis in an Acute Ischemic Stroke Patient on Direct Anticoagulant Therapy Outside of the Traditional Time Window: A Case Report. Cureus 2022; 14:e29673. [PMID: 36321003 PMCID: PMC9614184 DOI: 10.7759/cureus.29673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 11/11/2022] Open
Abstract
A stroke is a life-threatening medical condition that could be disabling if left untreated. Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) can be effective when initiated in an acute stroke, but their benefit is time-dependent and their use may be restricted by contraindications (CIs) such as anticoagulation therapy. The critical therapeutic time window, which was previously limited to 4.5-6 hours, is now extended to 24 hours in selected patients due to the development of advanced neuroimaging techniques. Herein, we discuss the case of a 50-year-old patient on rivaroxaban who developed acute ischemic stroke (AIS) and was treated successfully with intravenous recombinant tissue plasminogen activator thrombolysis more than six hours after the time he was last seen well (LSW). Our case demonstrates the importance of advanced neuroimaging techniques in identifying AIS candidates for IVT and/or MT with late or unknown time windows as well as the importance of case-by-case assessment when challenged by theoretical contraindications for thrombolysis.
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33
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Proença T, Pinto RA, Carvalho MMD, Sousa C, Dias P, Campelo M, Macedo F. Predictors of Atrial Fibrillation in Holter Monitoring after Stroke - A Ten Year Flashback. Arq Bras Cardiol 2022; 119:346-348. [PMID: 35946697 PMCID: PMC9363065 DOI: 10.36660/abc.20210660] [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: 08/09/2021] [Accepted: 03/09/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Tânia Proença
- Centro Hospitalar Universitário de São João, Porto - Portugal
| | | | | | - Carla Sousa
- Centro Hospitalar Universitário de São João, Porto - Portugal
| | - Paula Dias
- Centro Hospitalar Universitário de São João, Porto - Portugal
| | - Manuel Campelo
- Centro Hospitalar Universitário de São João, Porto - Portugal.,Universidade do Porto Faculdade de Medicina, Porto - Portugal
| | - Filipe Macedo
- Centro Hospitalar Universitário de São João, Porto - Portugal.,Universidade do Porto Faculdade de Medicina, Porto - Portugal
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34
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Ennab Vogel N, Tatlisumak T, Wester P, Lyth J, Levin LÅ. Prediction modelling the impact of onset to treatment time on the modified Rankin Scale score at 90 days for patients with acute ischaemic stroke. BMJ Neurol Open 2022; 4:e000312. [PMID: 36072349 PMCID: PMC9386213 DOI: 10.1136/bmjno-2022-000312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 07/20/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Shortening the time from stroke onset to treatment increases the effectiveness of endovascular stroke therapies. Aim This study aimed to predict the modified Rankin Scale score at 90 days post-stroke (mRS-90d score) in patients with acute ischaemic stroke (AIS) with respect to four types of treatment: conservative therapy (CVT), intravenous thrombolysis only (IVT), mechanical thrombectomy only (MT) and pretreatment with IVT before MT (IVT+MT). Patients and methods This nationwide observational study included 124 484 confirmed cases of acute stroke in Sweden over 6 years (2012–2017). The associations between onset-to-treatment time (OTT), patient age and hospital admission National Institutes of Health Stroke Scale (NIHSS) score with the five-levelled mRS-90d score were retrospectively studied. A generalised linear model (GLM) was fitted to predict the mRS-90d scores for each patient group. Results The fitted GLM for CVT patients is a function of age and NIHSS score. For IVT, MT and IVT+MT patients, GLMs additionally employed OTT variables. By reducing the mean OTTs by 15 min, the number needed-to-treat (NNT) for one patient to make a favourable one-step shift in the mRS was 30 for IVT, 48 for MT and 21 for IVT+MT. Discussion and conclusion This study demonstrates linear associations of mRS-90d score with OTT for IVT, MT and IVT+MT, and shows in absolute effects measures that OTT reductions for IVT and/or MT produces substantial health gains for patients with AIS. Even moderate OTT reductions led to sharp drops in the NNT.
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Affiliation(s)
- Nicklas Ennab Vogel
- Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Turgut Tatlisumak
- Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
| | - Per Wester
- Department of Public Health and Clinical Science, Umeå University, Umeå, Sweden
- Department of Clinical Science, Karolinska Institute Danderyds Hospital, Stockholm, Sweden
| | - Johan Lyth
- Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Lars-Åke Levin
- Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
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35
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von der Forst M, Morath B, Schwald M, Weigand MA, Schmitt FCF. [Principles of the perioperative management of direct oral anticoagulants]. DIE ANAESTHESIOLOGIE 2022; 71:565-576. [PMID: 35925055 DOI: 10.1007/s00101-022-01142-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 06/17/2023]
Abstract
Within the approved indications direct oral anticoagulants (DOAC) are increasingly gaining acceptance instead of vitamin K antagonists (VKA). In the last 12 months 5 guidelines relevant to the perioperative management of DOACs have been updated. This article summarizes the current recommendations for the perioperative management of treatment with DOACs. The available substances and their pharmacological properties as well as the possibilities for specific laboratory diagnostics of the effect of DOAC are explained. Special focus is placed on anesthesiologically important aspects of substance-specific preoperative and postoperative intermission intervals, the procedure for neuraxial regional anesthesia and antagonization with specific antidotes in cases of life-threatening bleeding.
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Affiliation(s)
- Maik von der Forst
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Benedict Morath
- Krankenhausapotheke, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 670, 69120, Heidelberg, Deutschland
| | - Martina Schwald
- Krankenhausapotheke, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 670, 69120, Heidelberg, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Felix C F Schmitt
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
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36
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Kersten CJBA, Zandbergen AAM, Berkhemer OA, Borst J, Haalboom M, Roos YBWEM, Dippel DWJ, van Oostenbrugge RJ, van der Lugt A, van Zwam WH, Majoie CB, den Hertog HM. Association of hyperglycemia and computed tomographic perfusion deficits in patients who underwent endovascular treatment for acute ischemic stroke caused by a proximal intracranial occlusion: A subgroup analysis of a randomized phase 3 trial (MR CLEAN). J Neurol Sci 2022; 440:120333. [PMID: 35834861 DOI: 10.1016/j.jns.2022.120333] [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: 01/29/2022] [Revised: 06/23/2022] [Accepted: 06/27/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Hyperglycemia is highly prevalent in patients with acute ischemic stroke and is associated with increased risk of symptomatic intracranial hemorrhage, larger infarct size and unfavorable outcome. Furthermore, glucose may modify the effect of endovascular treatment (EVT) in patients with ischemic stroke. Hyperglycemia might lead to accelerated conversion of penumbra into infarct core. However, it remains uncertain whether hyperglycemia on admission is associated with the size of penumbra or infarct core in acute ischemic stroke. In this study, we aimed to assess the association between hyperglycemia and Computed Tomographic Perfusion (CTP) derived parameters in patients who underwent EVT for acute ischemic stroke. METHODS We used data from the MR CLEAN study (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands). Hyperglycemia was defined as admission serum glucose of >7.8 mmol/L. Dichotomized and quantiles of glucose levels were related to size of core, penumbra and core penumbra ratio. Hypoperfused area is mean transient time 45% higher than that of the contralateral hemisphere. Core is the area with cerebral blood volume of <2 mL/100 g and penumbra is the area with cerebral blood volume > 2 mL/100 g. Core-penumbra ratio is the ischemic core divided by the total volume of hypoperfused tissue (core plus penumbra) multiplied by 100. Adjustments were made for age, sex, NIHSS on admission, onset-imaging time and diabetes mellitus. RESULTS Hundred seventy-three patients were included. Median glucose level on admission was 6.5 mmol/L (IQR 5.8-7.5 mmol/L) and thirty-five patients (20%) were hyperglycemic. Median core volume was 33.3 mL (IQR 13.6-62.4 mL), median penumbra volume was 80.2 mL (IQR 36.3-123.5 mL) and median core-penumbra ratio was 28.5% (IQR 18.6-45.8%). Patients with hyperglycemia on admission had larger core volumes and core penumbra ratio than normoglycemic patients with a regression coefficient of 15.1 (95% confidence interval (CI), 1.8 to 28.3) and 11.5 (95% confidence interval (CI), 3.4 to 19.7) respectively. CONCLUSION Hyperglycemia on admission was associated with larger ischemic core volume and larger core-penumbra ratio in patients with acute ischemic stroke who underwent endovascular treatment.
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Affiliation(s)
- C J B A Kersten
- Department of Neurology, Medisch Spectrum Twente, Enschede, the Netherlands.
| | - A A M Zandbergen
- Department of Internal Medicine, Erasmus Medisch Centrum, Rotterdam, the Netherlands
| | - O A Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - J Borst
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - M Haalboom
- Medical School Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Y B W E M Roos
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - D W J Dippel
- Department of Neurology, Erasmus Medisch Centrum, Rotterdam, the Netherlands
| | - R J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - A van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus Medisch Centrum, Rotterdam, the Netherlands
| | - W H van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - C B Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
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37
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Systematic Review of Existing Stroke Guidelines: Case for a Change. BIOMED RESEARCH INTERNATIONAL 2022; 2022:5514793. [PMID: 35722461 PMCID: PMC9199531 DOI: 10.1155/2022/5514793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/07/2022] [Indexed: 11/30/2022]
Abstract
Methods We systematically searched for guideline recommendation on the day-to-day use of peripheral inflammatory markers such as NLR published in the English language between January 1, 2005, and October 2020. Any other evidence of system biology-based approach or recommendation was explored within the selected guidelines for this scoping review. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 4 authors to determine clinical scenarios explained/given, scientific evidence used, and recommendations presented in the context of system biology. Results The scoping review found 2,911 titles at the beginning of the search. Final review included with 15 guidelines. Stroke-related organizations wrote sixty-five percent of the guidelines while national ministries wrote a fewer number of guidelines. We were primarily interested in recommendations for acute management in AIS published in the English language. Fifteen eligible guidelines were identified from 15 different countries/regions. None of the guidelines recommended the routine use of peripheral markers of inflammation, such as NLR, among their acute assessment and management recommendations. None of the existing guidelines explored the system biology approach to one of the most complex diseases affecting the human brain, stroke. Conclusions This systematic review has identified a significant evidence-practice gap in all existing national stroke guidelines published in English medium as of October 2020. These guidelines included the only current “living stroke guidelines,” stroke guidelines from Australia with a real opportunity to modernize the living stroke guidelines with systems biology approach, and provide 2020 vision towards better stroke care globally. Investigation of complex disease such as stroke is best served through a systems biology approach. One of the easiest places to start is simple blood tests such as total white cell count and NLR. Systems biology approach point us towards simple tools such immune-inflammatory index (SII) and serial systemic immune inflammatory indices (SSIIi) which should pave the way for the stroke physician community address the challenges in systems biology approach in stroke care. These challenges include translating bench research to the bedside, managing big data (continuous pulse, blood pressure, sleep, oxygen saturation, progressive changes in NLR, SII, SSIIi, etc.). Working with an interdisciplinary team also provides a distinct advantage. Recent adoption of historic WHO-IGAP calls for immediate action. The 2022 World Brain Day campaign on Brain Health for All is the perfect opportunity to raise awareness and start the process.
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38
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Jourdi G, Marquis-Gravel G, Martin AC, Lordkipanidzé M, Godier A, Gaussem P. Antiplatelet Therapy in Atherothrombotic Diseases: Similarities and Differences Across Guidelines. Front Pharmacol 2022; 13:878416. [PMID: 35571090 PMCID: PMC9092185 DOI: 10.3389/fphar.2022.878416] [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: 02/18/2022] [Accepted: 03/29/2022] [Indexed: 12/24/2022] Open
Abstract
Antiplatelet therapy, mainly consisting of aspirin and P2Y12 receptor antagonists, is the cornerstone of the pharmacological treatment and prevention of atherothrombotic diseases. Its use, especially in secondary cardiovascular prevention, has significantly improved patient clinical outcomes in the last decades. Primary safety endpoint (i.e., bleeding complications) remain a major drawback of antiplatelet drugs. National and international societies have published and regularly updated guidelines for antiplatelet therapy aiming to provide clinicians with practical recommendations for a better handling of these drugs in various clinical settings. Many recommendations find common ground between international guidelines, but certain strategies vary across the countries, particularly with regard to the choice of molecules, dosage, and treatment duration. In this review, we detail and discuss the main antiplatelet therapy indications in the light of the different published guidelines and the significant number of recently published clinical trials and meta-analyses and highlight the areas that deserve further investigation in order to improve antiplatelet therapy in patients with atherothrombotic diseases.
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Affiliation(s)
- Georges Jourdi
- Research Center, Montreal Heart Institute, Montreal, QC, Canada.,Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Guillaume Marquis-Gravel
- Research Center, Montreal Heart Institute, Montreal, QC, Canada.,Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Anne-Céline Martin
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, Paris, France.,Service de Cardiologie, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Marie Lordkipanidzé
- Research Center, Montreal Heart Institute, Montreal, QC, Canada.,Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Anne Godier
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, Paris, France.,Service d'Anesthésie Réanimation, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Pascale Gaussem
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, Paris, France.,Service d'Hématologie Biologique, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
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Huber C, Wachter R, Pelz J, Michalski D. Current Challenges and Future Directions in Handling Stroke Patients With Patent Foramen Ovale—A Brief Review. Front Neurol 2022; 13:855656. [PMID: 35572930 PMCID: PMC9103873 DOI: 10.3389/fneur.2022.855656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
The role of patent foramen ovale (PFO) in stroke was debated for decades. Randomized clinical trials (RCTs) have shown fewer recurrent events after PFO closure in patients with cryptogenic stroke (CS). However, in clinical practice, treating stroke patients with coexisting PFO raises some questions. This brief review summarizes current knowledge and challenges in handling stroke patients with PFO and identifies issues for future research. The rationale for PFO closure was initially based on the concept of paradoxical embolism from deep vein thrombosis (DVT). However, RCTs did not consider such details, limiting their impact from a pathophysiological perspective. Only a few studies explored the coexistence of PFO and DVT in CS with varying results. Consequently, the PFO itself might play a role as a prothrombotic structure. Transesophageal echocardiography thus appears most appropriate for PFO detection, while a large shunt size or an associated atrial septum aneurysm qualify for a high-risk PFO. For drug-based treatment alone, studies did not find a definite superiority of oral anticoagulation over antiplatelet therapy. Remarkably, drug-based treatment in addition to PFO closure was not standardized in RCTs. The available literature rarely considers patients with transient ischemic attack (TIA), over 60 years of age, and competing etiologies like atrial fibrillation. In summary, RCTs suggest efficacy for closure of high-risk PFO only in a small subgroup of stroke patients. However, research is also needed to reevaluate the pathophysiological concept of PFO-related stroke and establish strategies for older and TIA patients and those with competing risk factors or low-risk PFO.
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Affiliation(s)
- Charlotte Huber
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Rolf Wachter
- Department of Cardiology, University of Leipzig, Leipzig, Germany
| | - Johann Pelz
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Dominik Michalski
- Department of Neurology, University of Leipzig, Leipzig, Germany
- *Correspondence: Dominik Michalski
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40
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Meinel TR, Brignoli K, Kielkopf M, Clenin L, Beyeler M, Scutelnic A, Siepen B, Mueller M, Goeldlin M, Seiffge D, Kaesmacher J, Mujanovic A, Belachew NF, Fischer U, Arnold M, Gräni C, Seiler C, Buffle E, Jung S. Yield of Echocardiography in Ischemic Stroke and Patients With Transient Ischemic Attack With Established Indications for Long-Term Direct Oral Anticoagulant Therapy: A Cross-Sectional Diagnostic Cohort Study. J Am Heart Assoc 2022; 11:e024989. [PMID: 35475357 PMCID: PMC9238622 DOI: 10.1161/jaha.121.024989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background We aimed to determine the diagnostic yield of transthoracic (TTE) and transesophageal echocardiography (TEE) in patients with ischemic stroke and transient ischemic attack with established indications for direct oral anticoagulants before the index event. Methods and Results This was a retrospective cohort study of consecutive patients with preceding established indications for long‐term therapeutic direct oral anticoagulants presenting to a single comprehensive stroke center with ischemic stroke or transient ischemic attack. Choice of echocardiography modality was based on expert recommendations. The primary outcome was a composite of prespecified management‐relevant high‐risk findings adjudicated by an expert panel, based on TTE and TEE reports according to evidence‐based recommendations. Explorative analyses were performed to identify biomarkers associated with the primary outcome. Of 424 patients included (median [interquartile range] age, 78 [70–84] years; 175 [41%] women; National Institutes of Health Stroke Scale, 4 [1–12]; 67% atrial fibrillation), 292 (69%) underwent echocardiography, while 132 (31%) did not. Modality was TTE in 191 (45%) and TEE in 101 (24%). Median time from index event to echocardiography was 2 (1–3) days. TTE identified 26 of 191 (14%) patients with 35 management‐relevant pathologies. TEE identified 16 of 101(16%) patients with 20 management‐relevant pathologies. Most management‐relevant findings represented indicated coronary artery disease and valvular pathologies. In a further 3 of 191 (2%) patients with TTE and 4 of 101 (4%) patients with TEE, other relevant findings were identified. Variables associated with management‐relevant high‐risk pathologies included more severe stroke, diabetes, and laboratory biomarkers (NT‐proBNP [N‐terminal pro‐B‐type natriuretic peptide], C‐reactive protein, d‐dimer, and troponin levels). Conclusions In patients with established indications for long‐term direct oral anticoagulant therapy and stroke who received echocardiography, both TTE and TEE identified a relevant and similar proportion of management‐relevant high‐risk pathologies and predictive biomarkers could help to guide diagnostic workup in such patients.
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Affiliation(s)
- Thomas R Meinel
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Kristina Brignoli
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Moritz Kielkopf
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Leander Clenin
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Morin Beyeler
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Adrian Scutelnic
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Bernhard Siepen
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Madlaine Mueller
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Martina Goeldlin
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, InselspitalBern University Hospital Bern Switzerland
| | - Adnan Mujanovic
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland.,Institute of Diagnostic and Interventional Neuroradiology, InselspitalBern University Hospital Bern Switzerland
| | - Nebiyat F Belachew
- Institute of Diagnostic and Interventional Neuroradiology, InselspitalBern University Hospital Bern Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland.,Department of Neurology and Stroke Center University Hospital Basel and University of Basel Basel Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Christoph Gräni
- Department of Cardiology Inselspital BernBern University Hospital, and University of Bern Bern Switzerland
| | - Christian Seiler
- Department of Cardiology Inselspital BernBern University Hospital, and University of Bern Bern Switzerland
| | - Eric Buffle
- Department of Cardiology Inselspital BernBern University Hospital, and University of Bern Bern Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
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Embolic Protection with the TriGuard 3 System in Nonagenarian Patients Undergoing Transcatheter Aortic Valve Replacement for Severe Aortic Stenosis. J Clin Med 2022; 11:jcm11072003. [PMID: 35407611 PMCID: PMC8999484 DOI: 10.3390/jcm11072003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/21/2022] [Accepted: 03/28/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Transcatheter aortic valve replacement (TAVR) improves the survival and life quality of nonagenarian patients with aortic stenosis. Stroke remains one of the most worrisome complications following TAVR. Cerebral embolic protection devices (CEPDs) may reduce neurological complications after TAVR. This study evaluated the safety and efficacy of CEPDs during TAVR in nonagenarian patients. Methods: Between January 2018 and October 2021, 869 patients underwent transfemoral TAVR (TF-TAVR) at our center. Of these, 51 (5.9%) patients were older than ninety years. In 33 consecutive nonagenarian patients, TF-TAVR was implanted without CEPDs using balloon-expandable valves (BEVs) and self-expandable valves (SEVs). Eighteen consecutive nonagenarians underwent TF-TAVR using a CEPD (CP group). Follow up period was in-hospital or 30 days after the procedure, respectively. Results: Minor access site complications occurred in two patients (3.9%) and were not CEPD-associated. Postinterventional delirium occurred in nine patients (17.6%). Periprocedural minor non-disabling stroke and delirium occurred in ten patients (19.6%). Periprocedural major fatal stroke occurred in two patients in the BEV group (3.9%). Two patients in the BEV group died due to postinterventional pneumonia with sepsis. The mortality rate was 7.8%. The results did not differ between the groups. Conclusions: Age alone is no longer a contraindication for TAVR. CEPD using the Triguard 3 system in nonagenarian TAVR patients was feasible and safe and did not increase access site complications.
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Challenges in the hemodynamic management of acute nontraumatic neurological injuries. Curr Opin Crit Care 2022; 28:138-144. [PMID: 35102071 DOI: 10.1097/mcc.0000000000000925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To appraise the evidence from the literature and suggest an integrated hemodynamic approach of early and delayed phases of acute ischemic stroke (AIS), subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH). RECENT FINDINGS In AIS, the research aims to evaluate the optimal pressure control before, during and after the revascularization, to optimize the perfusion in the ischemic areas, minimizing the risk of hemorrhage or secondary damage to already infarcted areas. In the early phase of SAH, systemic pressure should be controlled to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure. The late phase aims to minimize the risk of cerebral vasospasm by adapting systemic pressure and volemia to cerebral and systemic physiological hemodynamic targets. In the mild-to-moderate ICH, achieving SAP of less than 140 mmHg and greater than 110 mmHg may be considered as a beneficial target. Caution should be considered in lowering intensively SAP in severe ICH. SUMMARY In nontraumatic brain injuries, the hemodynamic management is strictly related to fluctuating physiology of these diseases, needing a strict control of pressure and flow variable to ensure both cerebral and systemic homeostasis.
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Leys D, Casolla B, Cordonnier C. Low-Density Lipoprotein Cholesterol Level After a Stroke-Reducing It by Any Means. JAMA Neurol 2022; 79:329-330. [PMID: 35188953 DOI: 10.1001/jamaneurol.2021.5586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Didier Leys
- University of Lille, Inserm, CHU Lille, U1172-LilNCog-Lille Neuroscience & Cognition, Lille, France
| | - Barbara Casolla
- Stroke Unit, Hôpital Pasteur 2, URRIS-UR2CA, Unité de Recherche Clinique Cote d'Azur, Cote d'Azur University, Nice, France
| | - Charlotte Cordonnier
- University of Lille, Inserm, CHU Lille, U1172-LilNCog-Lille Neuroscience & Cognition, Lille, France
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Mac Grory B, Ohman EM, Feng W, Xian Y, Yaghi S, Kamel H, Reznik ME. Advances in the management of cardioembolic stroke associated with patent foramen ovale. BMJ 2022; 376:e063161. [PMID: 35140114 DOI: 10.1136/bmj-2020-063161] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patent foramen ovale (PFO) describes a valve in the interatrial septum that permits shunting of blood or thrombotic material between the atria. PFOs are present in approximately 25% of the healthy population and are not associated with any pathology in the vast majority of cases. However, comparisons between patients with stroke and healthy controls suggest that PFOs may be causative of stroke in certain patients whose stroke is otherwise cryptogenic. Options for the diagnosis of PFO include transthoracic echocardiography, transesophageal echocardiography, and transcranial Doppler ultrasonography. PFOs associated with an interatrial septal aneurysm seem to be more strongly linked to risk of recurrent stroke. Therapeutic options for secondary stroke prevention in the setting of a PFO include antiplatelet therapy, anticoagulation, and percutaneous device closure. Recent randomized clinical trials suggest that percutaneous closure reduces the subsequent risk of stroke in appropriately selected patients, with a large relative benefit but small absolute benefit. Referral for percutaneous PFO closure should therefore be considered in certain patients after a multidisciplinary, patient centered discussion. Areas for future study include structural biomarkers to aid in determining the role of PFO closure in older people with possible PFO associated stroke, the role of direct oral anticoagulants, and very long term outcomes after device closure.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Ying Xian
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Michael E Reznik
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Bicciato G, Arnold M, Gebhardt A, Katan M. Precision medicine in secondary prevention of ischemic stroke: how may blood-based biomarkers help in clinical routine? An expert opinion. Curr Opin Neurol 2022; 35:45-54. [PMID: 34839341 DOI: 10.1097/wco.0000000000001011] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW One in eight patients unfortunately suffers a new stroke within 5 years of their first stroke, even today. Research in precision medicine could lead to a more individualized treatment allocation, possibly achieving lower recurrence rates of ischemic stroke. In this narrative review, we aim to discuss potential clinical implementation of several promising candidate blood biomarkers. RECENT FINDINGS We discuss specifically some promising blood-based biomarkers, which may improve the identification of underlying causes as well as risk stratification of patients according to their specific cerebrovascular risk factor pattern. SUMMARY Multimodal profiling of ischemic stroke patients by means of blood biomarkers, in addition to established clinical and neuroradiological data, may allow in the future a refinement of decision algorithms for treatment allocation in secondary ischemic stroke prevention.
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Affiliation(s)
- Giulio Bicciato
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
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Oh M, Lee M. Clinical Implications of Prominent Cortical Vessels on Susceptibility-Weighted Imaging in Acute Ischemic Stroke Patients Treated with Recanalization Therapy. Brain Sci 2022; 12:brainsci12020184. [PMID: 35203945 PMCID: PMC8869791 DOI: 10.3390/brainsci12020184] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 02/04/2023] Open
Abstract
Prominent cortical vessels on susceptibility-weighted imaging (PCV–SWI) correlate with poor leptomeningeal collaterals. However, little is known about PCV–SWI in recanalization therapy-treated patients with anterior circulation large vessel occlusions (LVO). We investigated PCV–SWI-based assessment of leptomeningeal collaterals and outcome predictions in 100 such patients in an observational study. We assessed PCV–SWI using the Alberta Stroke Program Early CT Score and evaluated leptomeningeal collaterals on multiphase CT angiography (mCTA). Predictive abilities were analyzed using multivariable logistic regression and area of receiver operating curves (AUCs). The extent of PCV–SWI correlated with leptomeningeal collaterals on mCTA (Spearman test, r = 0.77; p < 0.001); their presence was associated with worse functional outcomes and a lower successful recanalization rate (adjusted odds ratios = 0.24 and 0.23, 95% CIs = 0.08–0.65 and 0.08–0.65, respectively). The presence of PCV–SWI predicted outcomes better than good collaterals on mCTA did (C-statistic = 0.84 vs. 0.80; 3-month modified Rankin Scale (mRS) 0–2 = 0.75 vs. 0.67 for successful recanalization). Comparison of AUCs showed that they had similar abilities for predicting outcomes (p = 0.68 for 3-month mRS 0–2; p = 0.23 for successful recanalization). These results suggest that PCV–SWI is a useful feature for assessing leptomeningeal collaterals in acute ischemic stroke patients with anterior circulation LVO and predicting outcomes after recanalization therapy.
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Jourdi G, Godier A, Lordkipanidzé M, Marquis-Gravel G, Gaussem P. Antiplatelet Therapy for Atherothrombotic Disease in 2022—From Population to Patient-Centered Approaches. Front Cardiovasc Med 2022; 9:805525. [PMID: 35155631 PMCID: PMC8832164 DOI: 10.3389/fcvm.2022.805525] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/06/2022] [Indexed: 12/20/2022] Open
Abstract
Antiplatelet agents, with aspirin and P2Y12 receptor antagonists as major key molecules, are currently the cornerstone of pharmacological treatment of atherothrombotic events including a variety of cardio- and cerebro-vascular as well as peripheral artery diseases. Over the last decades, significant changes have been made to antiplatelet therapeutic and prophylactic strategies. The shift from a population-based approach to patient-centered precision medicine requires greater awareness of individual risks and benefits associated with the different antiplatelet strategies, so that the right patient gets the right therapy at the right time. In this review, we present the currently available antiplatelet agents, outline different management strategies, particularly in case of bleeding or in perioperative setting, and develop the concept of high on-treatment platelet reactivity and the steps toward person-centered precision medicine aiming to optimize patient care.
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Affiliation(s)
- Georges Jourdi
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- *Correspondence: Georges Jourdi
| | - Anne Godier
- Université de Paris, Innovative Therapies in Haemostasis, INSERM UMR_S1140, Paris, France
- Department of Anesthesiology and Critical Care, AP-HP, Université de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Marie Lordkipanidzé
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Guillaume Marquis-Gravel
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Pascale Gaussem
- Université de Paris, Innovative Therapies in Haemostasis, INSERM UMR_S1140, Paris, France
- Service d'Hématologie Biologique, AP-HP, Université de Paris, Hôpital Européen Georges Pompidou, Paris, France
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Dell'Aera C, Giammello F, Caragliano AA, Ciacciarelli A, Francalanza I, Currò CT, Pitrone A, Grillo F, Casella C, Fazio MC, La Spina P, Cotroneo M, Crea P, Toscano A, Vinci SL, Musolino RF. Repeated reperfusion treatment in recurrent ischemic stroke: A retrospective single-center case series. J Neurol Sci 2022; 434:120147. [PMID: 35033745 DOI: 10.1016/j.jns.2022.120147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/15/2021] [Accepted: 01/05/2022] [Indexed: 11/28/2022]
Abstract
Data regarding repeated reperfusion therapy (rRT) in acute ischemic stroke (AIS), including intravenous thrombolysis and endovascular treatment (EVT), are quite poor. To date, there are only few case reports and five larger studies on repeated EVT. We aimed to report our single-center experience and describe different clinical scenarios of recurrent AIS with emergent large vessel occlusion (LVO), for which the decision-making process could be challenging in the emergency setting. We retrospectively reviewed 765 consecutive AIS patients with LVO, who underwent reperfusion procedures at our comprehensive stroke center, from 2014 to 2020, and identified rRT patients. We identified and reviewed the medical records of eight patients (1.05%), who repeated reperfusive treatment for recurrent stroke within 30 days (early arterial reocclusion, EAR) and after 30 days (late arterial reocclusion, LAR). We assigned collected data to three clinical scenarios, each divided into EAR and LAR cases. All patients had recurrent emergent LVO in the same vessel territory previously affected, both in EAR and LAR patients. A good clinical outcome has been achieved in EAR patients (modified Rankin Score ≤ 2). Artery-to-artery embolic mechanism was more common in the EAR group, while LAR was more frequently associated with cardioembolic source. RRT appears to be an effective treatment option for recurrent LVO, and it should not be withheld in carefully selected patients. EVT should be considered, including aspiration-only and stenting procedures in patients with AIS and recurrent LVO after previous reperfusive treatments, even after a very short time.
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Affiliation(s)
- Cristina Dell'Aera
- U.O.S.D. Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Fabrizio Giammello
- International PhD Translational Molecular Medicine and Surgery, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy.
| | - Antonio Armando Caragliano
- Neuroradiology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Antonio Ciacciarelli
- U.O.S.D. Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Isabella Francalanza
- U.O.S.D. Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Carmelo Tiberio Currò
- U.O.S.D. Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonio Pitrone
- Neuroradiology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Francesco Grillo
- U.O.S.D. Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Carmela Casella
- U.O.S.D. Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Maria Carolina Fazio
- U.O.S.D. Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Paolino La Spina
- U.O.S.D. Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Masina Cotroneo
- U.O.S.D. Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Pasquale Crea
- Cardiology Unit with U.T.I.C., Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonio Toscano
- Unit of Neurology and Neuromuscular Disorders, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Sergio Lucio Vinci
- Neuroradiology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Rosa Fortunata Musolino
- U.O.S.D. Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Khoujah D, Chang WTW. The emergency neurology literature 2020. Am J Emerg Med 2022; 54:1-7. [DOI: 10.1016/j.ajem.2022.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 01/03/2022] [Accepted: 01/10/2022] [Indexed: 10/19/2022] Open
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50
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Beltrán Romero LM, Vallejo-Vaz AJ, Muñiz Grijalvo O. Cerebrovascular Disease and Statins. Front Cardiovasc Med 2021; 8:778740. [PMID: 34926626 PMCID: PMC8674469 DOI: 10.3389/fcvm.2021.778740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/08/2021] [Indexed: 12/21/2022] Open
Abstract
Elevated low-density lipoprotein-cholesterol (LDL-C) is a causal factor for the development of atherosclerotic cardiovascular disease (ASCVD); accordingly, LDL-C lowering is associated with a decreased risk of progression of atherosclerotic plaques and development of complications. Currently, statins play a central role in any ASCVD management and prevention strategies, in relation to their lipid-lowering action and potentially to pleiotropic effects. After coronary artery disease, stroke is the most frequent cause of ASCVD mortality and the leading cause of acquired disability, a major public health problem. There is often a tendency to aggregate all types of stroke (atherothrombotic, cardioembolic, and haemorrhagic), which have, however, different causes and pathophysiology, what may lead to bias when interpreting the results of the studies. Survivors of a first atherothrombotic ischemic stroke are at high risk for coronary events, recurrent stroke, and vascular death. Although epidemiological studies show a weak relationship between cholesterol levels and cerebrovascular disease as a whole compared with other ASCVD types, statin intervention studies have demonstrated a decrease in the risk of stroke in patients with atherosclerosis of other territories and a decrease in all cardiovascular events in patients who have had a stroke. The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial demonstrated the benefit of high doses of atorvastatin in the secondary prevention of ischemic stroke. In this review, we discuss the evidence, use and recommendations of statins in the primary and secondary prevention of stroke, and their role in other scenarios such as the acute phase of ischemic stroke, cerebral hemorrhage, cardioembolic stroke, small vessel disease, and cognitive impairment.
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Affiliation(s)
- Luis M Beltrán Romero
- Internal Medicine, Virgen del Rocío University Hospital, Seville, Spain.,Clinical Epidemiology and Vascular Risk, Instituto de Biomedicina de Sevilla, IBiS/Hospital Universitario Virgen del Rocío/Universidad de Sevilla/CSIC, Seville, Spain.,Department of Medicine, Faculty of Medicine, University of Seville, Seville, Spain
| | - Antonio J Vallejo-Vaz
- Clinical Epidemiology and Vascular Risk, Instituto de Biomedicina de Sevilla, IBiS/Hospital Universitario Virgen del Rocío/Universidad de Sevilla/CSIC, Seville, Spain.,Department of Medicine, Faculty of Medicine, University of Seville, Seville, Spain
| | - Ovidio Muñiz Grijalvo
- Internal Medicine, Virgen del Rocío University Hospital, Seville, Spain.,Clinical Epidemiology and Vascular Risk, Instituto de Biomedicina de Sevilla, IBiS/Hospital Universitario Virgen del Rocío/Universidad de Sevilla/CSIC, Seville, Spain
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