Physician Approaches to Antithrombotic Therapies for Recently Symptomatic Carotid Stenosis

BACKGROUND

Whereas the beneficial effect of antiplatelet therapy for recurrent stroke prevention has been well established, uncertainties remain regarding the optimal antithrombotic regimen for recently symptomatic carotid stenosis. We sought to explore the approaches of stroke physicians to antithrombotic management of patients with symptomatic carotid stenosis.

METHODS

We employed a qualitative descriptive methodology to explore the decision-making approaches and opinions of physicians regarding antithrombotic regimens for symptomatic carotid stenosis. We conducted semi-structured interviews with a purposive sample of 22 stroke physicians (11 neurologists, 3 geriatricians, 5 interventional-neuroradiologists, and 3 neurosurgeons) from 16 centers on four continents to discuss symptomatic carotid stenosis management. We then conducted thematic analysis on the transcripts.

RESULTS

Important themes revealed from our analysis included limitations of existing clinical trial evidence, competing surgeon versus neurologist/internist preferences, and the choice of antiplatelet therapy while awaiting revascularization. There was a greater concern for adverse events while using multiple antiplatelet agents (e.g., dual-antiplatelet therapy (DAPT)) in patients undergoing carotid endarterectomy compared to carotid artery stenting. Regional variations included more frequent use of single antiplatelet agents among European participants. Areas of uncertainty included antithrombotic management if already on an antiplatelet agent, implications of nonstenotic features of carotid disease, the role of newer antiplatelet agents or anticoagulants, platelet aggregation testing, and timing of DAPT.

CONCLUSION

Our qualitative findings can help physicians critically examine the rationale underlying their own antithrombotic approaches to symptomatic carotid stenosis. Future clinical trials may wish to accommodate identified variations in practice patterns and areas of uncertainty to better inform clinical practice.

AB0208 LONG-RUN RELATIONSHIP ASSESSMENT OF AIR POLLUTANTS ON RHEUMATOID ARTHRITIS DISEASE ACTIVITY SCORE: EVIDENCE FROM THE VECM APPROACH

Background

Current findings on the impact of air quality conditions on rheumatoid arthritis (RA) are sparse and not conclusive.

Objectives

To investigate the relationship between air pollutants and RA disease activity scores on a short and a long time period using a multivariate time series model.

Methods

Data on RA patients were extracted from the Kuwait Registry for Rheumatic Diseases (KRRD) from four major hospitals in Kuwait from January 2013 to December 2017. Data on air ambient pollutants (ozone O3, sulfur dioxide SO2, nitrogen dioxide NO2) were extracted from four Kuwait Environmental Public Authority (K-EPA) Air Monitoring Stations through Environmental Monitoring Information System of Kuwait (eMISK), corresponding to the patients residential areas from January 2013 till December 2020. A multivariate time series approach using Evidence from vector error correction model (VECM) was employed to investigate the effect of air ambient pollutants emissions on DAS28 over that period.

Results

A total of 1,809 RA patients and 10,215 hospital visits were included, 63% females, mean age 54 years, mean disease duration 9.2 years and 77% had rheumatoid factor positive. A significant correlation was found between DAS-28 and SO2, NO2 and O3 (p=0.012, 0.029, 0.039 respectively). According to the Granger causality test and VECM, emissions of NO2, and O3 had a positive short-term effect on DAS28 among RA patients. Impulse response test results showed that for some locations in Kuwait there is a short-term positive causal relationship between emissions of NO2 and DAS28, due to sources of pollution surrounding the locations. The results showed that the short run effect for NO2 with lags 1 to 4 days had a positive relationship with DAS-28 which means, there is 1% increase in DAS-28 for every 0.0182 increase in NO2 emission. Our results revealed that 36% of discrepancy between the overall relationship between DAS-28 and air pollution is corrected each year.

Conclusion

Increased concentrations of air pollutants may increase the risk of RA activity. VECM time series model can be used as a tool to predict changes in disease activity based on air pollutants up to 8 days. We recommend that a regular broadcast is issued by health authorities to RA patients to help predict changes in disease activity. Warning about air pollution may be tailored according to the patient’s residential area. Government should take serious decisions to help minimize air pollution in the residential areas.

References

[1]Chang, K.-H., Hsu, C.-C., Muo, C.-H., Hsu, C. Y., Liu, H.-C., Kao, C.-H., Chen, C.- Y., Chang, M.-Y., and Hsu, Y.-C. (2016). Air pollution exposure increases the risk of rheumatoid arthritis: a longitudinal and nationwide study. Environment International, 94:495–499.

[2]Alsaber, A., Pan, J., Al-Herz, A., Alkandary, D. S., Al-Hurban, A., Setiya, P., Group, K., et al. (2020). Influence of ambient air pollution on rheumatoid arthritis disease activity score index. International Journal of Environmental Research and Public Health, 17(2):416.

[3]Adami, G., Viapiana, O., Rossini, M., Orsolini, G., Bertoldo, E., Giollo, A., ... & Fassio, A. (2021). Association between environmental air pollution and rheumatoid arthritis flares. Rheumatology.

[4]Al-Herz, A., Al-Awadhi, A., Saleh, K., Al-Kandari, W., Hasan, E., Ghanem, A., Abutiban, F., Alenizi, A., Hussain, M., Ali, Y., et al. (2016). A comparison of rheumatoid arthritis patients in kuwait with other populations: results from the krrd registry. Journal of Advances in Medicine and Medical Research, pages 1–11.

[5]Al-Hurban, A., Khader, S., Alsaber, A., and Pan, J. (2021). Air quality assessment in the state of kuwait during 2012 to 2017. Atmosphere, 12(6):678.

Figure 1.

Long-term (2012-2020) trends of NO2 concentrations and DAS-28 calculated using the smooth trend method based on the mean measurements for four locations in Kuwait

Disclosure of Interests

None declared

Thrombus Migration and Fragmentation After Intravenous Alteplase Treatment: The INTERRSeCT Study

BACKGROUND AND PURPOSE

There is interest in what happens over time to the thrombus after intravenous alteplase. We study the effect of alteplase on thrombus structure and its impact on clinical outcome in patients with acute stroke.

METHODS

Intravenous alteplase treated stroke patients with intracranial internal carotid artery or middle cerebral artery occlusion identified on baseline computed tomography angiography and with follow-up vascular imaging (computed tomography angiography or first run of angiography before endovascular therapy) were enrolled from INTERRSeCT study (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography). Thrombus movement after intravenous alteplase was classified into complete recanalization, thrombus migration, thrombus fragmentation, and no change. Thrombus migration was diagnosed when occlusion site moved distally and graded according to degrees of thrombus movement (grade 0-3). Thrombus fragmentation was diagnosed when a new distal occlusion in addition to the primary occlusion was identified on follow-up imaging. The association between thrombus movement and clinical outcome was also evaluated.

RESULTS

Among 427 patients in this study, thrombus movement was seen in 54% with a median time of 123 minutes from alteplase administration to follow-up imaging, and sub-classified as marked (thrombus migration grade 2-3 + complete recanalization; 27%) and mild to moderate thrombus movement (thrombus fragmentation + thrombus migration grade 0-1; 27%). In patients with proximal M1/internal carotid artery occlusion, marked thrombus movement was associated with a higher rate of good outcome (90-day modified Rankin Scale, 0-2) compared with mild to moderate movement (52% versus 27%; adjusted odds ratio, 5.64 [95% CI, 1.72-20.10]). No difference was seen in outcomes between mild to moderate thrombus movement and no change. In M1 distal/M2 occlusion, marked thrombus movement was associated with improved 90-day good outcome compared with no change (70% versus 56%; adjusted odds ratio, 2.54 [95% CI, 1.21-5.51]).

CONCLUSIONS

Early thrombus movement is common after intravenous alteplase. Marked thrombus migration leads to good clinical outcomes. Thrombus dynamics over time should be further evaluated in clinical trials of acute reperfusion therapy.

Haematological, lipid profile and other biochemical parameters in normal and hypertensive subjects among the population of the eastern province of Saudi Arabia

OBJECTIVE

To determine the lipid profile complete blood count and other biochemical parameters in normotensive and hypertensive individuals.

DESIGN

Cross-sectional population-based epidemiological household survey.

SETTING

Population sample of the Eastern Province of Saudi Arabia.

RESULTS

Hypertensive individuals had significantly higher mean levels of glucose, Tc, LDL-c, HDL-c, triglycerides and HBAIc, compared to normotensive individuals while there were no significant difference in the mean levels of Apo AI and Apo B. Within the same group there were variations in the levels of certain parameters between male and female. While the mean levels of haemoglobin, WBC and platelets were significantly higher in the hypertensive group compared to normotensive, there were no significant differences between these two groups in the levels of RBC, MCV, HCT, MCH and MCHC. However, the mean levels haemoglobin, RBC count and HCT were significantly higher in male compared to female within the same group with no significant difference in levels of WBC, MCV, MCH and MCHC. Furthermore, the mean concentration of platelets was significantly higher in females compared to male within the same group. Hypertensive individuals had significantly higher serum sodium, chloride and calcium levels but a significantly lower potassium level when compared to normotensive with no siginificant differences between male and female within the same group.

CONCLUSION

The lipid and electrolyte profile of hypertensive individuals differ from that of normotensive individuals in this population. This study has contributed towards establishing the normal values for a number of parameters involved in the aetiology of cardiovascular diseases in the population of Eastern province.

Empty sella syndrome: does it exist in children?

OBJECT

The empty sella syndrome (ESS) is well documented in adults, and although the same phenomenon of herniation of the arachnoid space into the enlarged sella turcica has been noted in children, it is not widely known that children suffer from this syndrome. Therefore, the aims of this paper are to increase neurosurgeons' awareness of the existence of this phenomenon in children and to add to the scant body of literature on the subject.

METHODS

The authors treated 12 children, ranging in age between 2 and 8 years, in whom neuroradiological studies demonstrated an enlarged sella turcica filled with cerebrospinal fluid and herniation of suprasellar and arachnoid spaces. The causes of ESS in these children were high intracranial pressure, neglected or improperly treated hydrocephalus, and suprasellar arachnoid cyst. Primary ESS was found as well. Most of the children presented with headache, abnormal body weight (the majority being underweight), and short stature. The results of hormone assays were normal in all children.

CONCLUSIONS

If undiagnosed and untreated, ESS in children may lead to serious consequences, including impairment of pituitary and hypothalamic function and damage to the optic chiasm. It is important to raise awareness in the neurosurgical community about the existence of ESS in children so that it can be diagnosed and treated at an early stage. A classification system for the diaphragma sellae is recapitulated.