Intravenous Tissue Plasminogen Activator Improves the Outcome in Very Elderly Korean Patients with Acute Ischemic Stroke

David G. Sherman Lecture Award: 15-Year Experience of the Nationwide Multicenter Stroke Registry in Korea

The expected growth of stroke burden in Korea in early 2000s led to the initiation of a government-funded clinical research project with the goal of development and implementation of national stroke guidelines. The CRCS-K (Clinical Research Collaboration for Stroke in Korea) began as a part of this project. For stroke epidemiology and quality of care research, the CRCS-K developed a multicenter, prospective, stroke registry and began collection of data in 2008. Now, about 100 000 cases have been registered at 17 university hospitals or regional stroke centers and about 200 articles have been published based on the registry experience. The analysis of the 10-year secular trends showed overall improvement of stroke care and outcomes and areas for improvement. This large-scale, high-quality dataset provides opportunities to explore and compare treatment disparities using the comparative effectiveness research methods, design and conduct a registry-based randomized clinical trial, connect the registry data with other data sources including the national claims data and neuroimaging or genetic data, and collaborate with other international researchers. An international stroke registry consortium may be a viable future direction.

Improving Visualization Methods of Utility-Weighted Disability Outcomes for Stroke Trials

Background

The modified Rankin Scale (mRS) is the most common endpoint in acute stroke trials, but its power is limited when analyzed dichotomously and its indication of effect size is challenging to interpret when analyzed ordinally. To address these issues, the utility-weighted-mRS (UW-mRS) has been developed as a patient-centered, linear scale. However, appropriate data visualizations of UW-mRS results are needed, as current stacked bar chart displays do not convey crucial utility-weighting information.

Design/Methods

Two UW-mRS display formats were devised: (1) Utility Staircase charts, and (2) choropleth-stacked-bar-charts (CSBCs). In Utility Staircase displays, mRS segment height reflects the utility value of each mRS level. In CSBCs, mRS segment color intensity reflects the utility of each mRS level. Utility Staircase and CSBC figures were generated for 15 randomized comparisons of acute ischemic/hemorrhagic stroke therapies, including fibrinolysis, endovascular reperfusion, blood pressure moderation, and hemicraniectomy. Display accuracy in showing utility outcomes was assessed with the Tufte-lie-factor and ease-of-use assessed by formal ratings completed by a panel of 4 neurologists and emergency physicians and one nurse-coordinator.

Results

The Utility Staircase and CSBC displays rapidly conveyed patient-centered valuation of trial outcome distributions not available in conventional ordinal stacked bar charts. Tufte-lie-factor (LF) scores indicated “substantial distortion” of utility-valued outcomes for 93% (14/15) of conventional stacked bar charts, vs. “no distortion” for all Utility Staircase and CSBC displays. Clinician ratings on the Figural Display Questionnaire indicated that utility information encoded in row height (Utility Staircase display) was more readily assimilated than that conveyed in segment hue intensity (CSBC), both superior to conventional stacked bar charts.

Conclusions

Utility Staircase displays are an efficient graphical format for conveying utility weighted–modified Rankin Scale primary endpoint results of acute stroke trials, and choropleth-stacked-bar-charts a good alternative. Both are more accurate in depicting quantitative, health-related quality of life results and preferred by clinician users for utility results visualization, compared with conventional stacked bar charts.

Takotsubo-Like Myocardial Dysfunction in Ischemic Stroke: A Hospital-Based Registry and Systematic Literature Review

BACKGROUND AND PURPOSE

We investigated clinical and radiological characteristics of ischemic stroke patients with Takotsubo-like myocardial dysfunction.

METHODS

From multicenter stroke registry database, ischemic stroke patients who underwent transthoracic echocardiography were found. Among these, patients were classified if they had specific ventricular regional wall motion abnormalities discording with coronary artery distribution, such as apical (typical pattern) or nonapical ballooning (atypical pattern), considered as echocardiographic findings of Takotsubo cardiomyopathy. Patients with ischemic heart disease history, myocarditis, or pheochromocytoma were excluded. We compared patients with Takotsubo-like myocardial dysfunction with those without and further performed systematic literature review on those with Takotsubo cardiomyopathy.

RESULTS

This study included 23 patients (0.42%). The mean age was 70.7±13.9 years, with predominance of women (73.9%) and typical pattern of Takotsubo-like myocardial dysfunction (91.3%). They were associated with short-term poor functional outcomes, including high mortality, neurological deterioration, and functional status at discharge, compared with those without (39.1% versus 2.4%, 47.8% versus 7.4%; and median [interquartile range], 5 [5-6] versus 3 [2-4]; all P<0.001). They had a higher inflammatory marker level and lower triglyceride level. Ischemic lesions were more commonly found in the right anterior circulation with specific dominant regions being the insula and peri-insular areas. In addition, a trend toward a remarkable mortality rate and higher prevalence of insular involvement was observed in the propensity-score matching, subgroup fulfilling the strict Takotsubo cardiomyopath criteria, and was as reported in literature review.

CONCLUSION

Stroke patients with Takotsubo-like myocardial dysfunction may differ from those without in clinical outcomes, laboratory findings, and radiological features.