Selection bias may have affected enrollment in first generation endovascular stroke trials. We investigate, evaluate, and quantify such bias for these trials at our institution.
Demographic, ...clinical, imaging, and angiographic data were prospectively collected on a consecutive cohort of patients with acute ischemic stroke who were enrolled in formal trials of endovascular stroke therapy (EST) or received EST in clinical practice outside of a randomized trial for acute cerebral ischemia at a single tertiary referral center from September 2004 to December 2012.
Among patients considered appropriate for EST in practice, 47% were eligible for trials, with rates for individual trials ranging from 17% to 70%. Compared with trial ineligible patients treated with EST, trial eligible patients were younger (67 vs. 74 years; p<0.05), more often treated with intravenous tissue plasminogen activator (53% vs. 34%; p<0.01), and had shorter last known well to puncture times (328 vs. 367 min; p<0.05). Focusing on the largest trial with a non-interventional control arm, compared with trial eligible patients treated with EST outside the trial, enrolled patients presented later (274 vs. 163 min; p<0.001), had higher National Institutes of Health Stroke Scale scores (20 vs. 17; p<0.05), and larger strokes (diffusion weighted imaging volumes 49 vs. 18; p<0.001).
The majority of patients felt suitable for EST at our institution were excluded from recent trials. Formal entry criteria succeeded in selecting patients with better prognostic features, although many of these patients were treated outside of trials. Acknowledging and mitigating these biases will be crucial to ongoing investigations.
ABSTRACT
BACKGROUND
We examined the correlation of angiographic collaterals in acute stroke with the presence, extent, and distribution of white matter changes, so‐called Leukoaraiosis, in an effort ...to determine if Leukoaraiosis indicates chronic cerebral hypoperfusion and/or is associated with the development of cerebral collateral circulation.
METHODS
Consecutive acute strokes due to large‐vessel occlusion on angiography had preprocedure CT or MRI white matter changes graded utilizing the Fazekas scale incorporating deep and periventricular components. Angiographic collaterals evaluated with a 5‐point scale were correlated with leukoaraiosis.
RESULTS
Collaterals were evaluated in 102 cases (51 men, 51 women; mean age 66 (SD 18) years with acute occlusions of the proximal middle cerebral artery (MCA) (47%), distal internal carotid artery (ICA) (28%), distal MCA (9%), basilar (7%), proximal ICA (7%), vertebral (1%), posterior cerebral artery (PCA) (1%), and common carotid artery (CCA) (1%). Collateral grade was well distributed across the scale. Periventricular and deep white matter changes were evident in 34% and 51% of cases, respectively. Collateral grade exhibited no relationship with either the presence or extent of periventricular disease (P= .772, r= .029) or deep white matter changes (P= .559, r=−.059).
CONCLUSIONS
Leukoaraisosis exhibits no overt relationship with the extent of collaterals measured at angiography in acute ischemic stroke. Chronic small‐vessel disease may be a distinct pathophysiologic entity unrelated to arteriogenesis and compensatory aspects of collateral flow.
Abstract Background Conflicting data exist on the role of antiplatelet agents in reducing incident ischemic stroke magnitude, but most prior studies used clinically-assessed neurologic deficit as the ...index of stroke extent rather than more precise volumetric measurements of infarct size. We assessed the relation of premorbid antiplatelet use to initial diffusion-weighted MRI (DWI) lesion volumes among acute ischemic stroke patients. Methods Consecutive patients presenting within 24 h of ischemic stroke over an 18-month period were studied. DWI lesions were outlined using a semi-automated threshold technique. Subjects were categorized into two groups: antiplatelet (AP) or no antithrombotic (NA). The relationship between prestroke antithrombotic status and DWI infarct volumes was examined using multivariate quantile regression. Results One hundred sixty-six individuals met study criteria: 75 AP and 91 NA patients. Median DWI volume was lower in the AP group than in the NA group (1.5 cc vs. 5.4 cc, p = 0.031). A multivariable model (adjusting for age, history of transient ischemic attack, admission temperature, admission blood pressure, admission serum glucose, stroke onset to imaging interval, stroke mechanism, premorbid statin and antihypertensive use) demonstrated smaller infarcts in the AP vs. NA group (adjusted volume difference: − 1.3 cc, 95% CI = − 0.09, − 2.5, p = 0.037). Prior statin use, no history of TIA, large vessel atherosclerosis and microvascular ischemic disease stroke mechanism were also independently associated with reduced infarct volume. Conclusions Prior antiplatelet treatment is independently associated with reduced cerebral infarct volume among acute ischemic stroke patients. Premorbid statin use, TIA history and stroke mechanism also predict infarct volume in ischemic stroke.
The Framingham Coronary Risk Score (FCRS) is based on several factors, including age, sex, total cholesterol, high-density lipoprotein cholesterol, systolic blood pressure, presence of diabetes, and ...cigarette smoking. Some of these factors are individually linked with acute stroke outcomes. We explored whether FCRS could predict outcome in patients hospitalized with recent stroke. We collected data on consecutive patients hospitalized for ischemic stroke over a 3-year period. Patients with known coronary artery disease were excluded. Discharge outcomes assessed were neurologic deficit (National Institutes of Health Stroke Scale NIHSS score), death or disability (modified Rankin Scale mRS score ≥2), and discharge to home directly from the hospital. The independent effect of FCRS on these outcomes was evaluated using multivariate regression analysis. During the study period, 434 patients with ischemic stroke met entry criteria (mean age, 64.5 years; 54% females). Median FCRS score was 8%. After adjusting for confounders, higher FCRS score was associated with an increased likelihood of death or being disabled at discharge (odds ratio OR = 4.9; 95% confidence interval CI = 0.98-24.1; P = .05), and a decreased likelihood of being discharged directly to home (OR = 0.18; 95% CI = 0.04-0.86; P = .032), but not with discharge NIHSS score. Higher FCRS in hospitalized ischemic stroke patients is associated with death or disability at discharge and a lower likelihood of being discharged directly to home. Along with indexing the long-term risk of cardiovascular events, this widely known, easily calculable score provides clinically relevant short-term prognostic information following ischemic stroke.
BACKGROUNDLarge, long-term population data indicate an inverse association for adult height with stroke incidence and mortality, whereas the risk of atrial fibrillation appears greater in taller ...individuals. However, it is unclear whether knowledge of an individualʼs stature is an important clinical factor to consider when assessing hospitalized patients with ischemic stroke. We determined the relation of body height with clinical characteristics and discharge outcomes among persons with ischemic stroke.
METHODSWe analyzed prospectively collected data in 881 consecutive patients with ischemic stroke admitted to a university hospital stroke service during a 5-year period starting September 2002. Stroke subtyping was performed per modified Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria. Stroke severity was assessed with the National Institutes of Health Stroke Scale. All patients were assessed at discharge using the modified Rankin scale. Mean adjusted height was compared using linear regression models with height as outcome, and stroke subtype, modified Rankin scale, and potential confounders as covariates.
RESULTSMean age was 67.4 years, 48% were women. Mean height was 169 cm (SD±11). In multivariable analysis, height decreased per year of age (P=0.003), those with a previous stroke were shorter than those without a previous stroke (P=0.04), and females were shorter than males (P<0.001). Height was not associated with stroke subtype or discharge outcomes in unadjusted or adjusted analyses.
CONCLUSIONSBody height at hospital admission has no relation to ischemic stroke subtype or discharge outcome. However, patients with history of previous stroke were significantly shorter than those without a previous stroke, which may be because of greater stroke occurrence in shorter individuals or taller people with relatively larger atrial fibrillation-related strokes dying earlier.
Background
The influence of lesion size and laterality on each component of the National Institutes of Health Stroke Scale has not been delineated. The objective of this study was to use ...perfusion-weighted imaging to characterize the association of ischaemic volume and laterality on each component item and the total score of the <National Institutes of Health Stroke Scale.
Methods
We analysed consecutive right-handed patients with first-ever supratentorial acute ischaemic strokes who underwent acute perfusion-weighted imaging at a single centre. Perfusion deficits were defined as mean transit time > 10 s. Ordinal regression was used to clarify the relationship between ischaemic volume, laterality, and <National Institutes of Health Stroke Scale scores.
Results
Among 111 patients, 58 were left-hemisphere stroke, and 53 right-hemisphere stroke. Median ischaemic volume was 53 ml in left-hand stroke and 65 ml in right-hand stroke and median total National Institutes of Health Stroke Scale was 10 in left-hand stroke and eight in right-hand stroke. For individual National Institutes of Health Stroke Scale items, ischaemic volume correlated most closely with commands and visual field and most weakly with ataxia and neglect. Left-hand stroke predicted higher scores of total National Institutes of Health Stroke Scale and National Institutes of Health Stroke Scale items of questions, commands, right limb weakness, and language. Right-hand stroke predicted higher scores of left limb weakness and extinction.
Conclusions
Larger perfusion defects contribute to higher scores on the total and most individual items of the National Institutes of Health Stroke Scale. However, lesion laterality contributes substantially to half the item scores, with greater association of left than right-brain side. These findings indicate that imaging-deficit correlations will be improved by designating lesions into an atlas, taking into account side in addition to size.
Background Although influenza-related morbidity and mortality is high, and influenza can be a trigger for recurrent stroke, only about half of stroke survivors receive yearly influenza vaccination. ...Identifying new avenues through which to optimize influenza vaccination among stroke survivors is a public health need. We assessed the feasibility of integrating influenza vaccination into routine inpatient stroke care. Methods We designed a quality improvement project incorporating influenza vaccination into care administered to hospitalized patients with ischemic stroke and transient ischemic attack that included a standardized order and discharge checklist. Data were then prospectively collected on consecutively encountered patients with ischemic stroke and transient ischemic attack admitted to a university hospital stroke service during the influenza season of October 2007 to February 2008. Successful influenza treatment use was based on optimal rather than actual treatment, with credit for optimal treatment given if an acceptable reason for nonadministration of the vaccine was documented. Results Of 103 patients admitted during the study period, 75 (73%) were eligible for influenza vaccination (mean age 72.8 years; 51% women). Among vaccination-eligible patients, 65 (87%) received optimal influenza vaccination treatment, whereas 14 (21%) actually received the vaccination during hospitalization. Leading reason (90%) for suboptimal influenza vaccination treatment among eligible patients was that the vaccination was inadvertently not ordered on admission or at discharge. Conclusions Influenza vaccination can be systematically incorporated into stroke hospitalization and may be a viable avenue for promptly enhancing short-term clinical outcomes among hospitalized patients with stroke during peak influenza season.
The stroke patient who deteriorates presents a common and rewarding diagnostic challenge. Up to one third of ischemic stroke patients worsen after admission, though the frequency of deterioration is ...declining with modern supportive care. The causes of clinical worsening are diverse; common etiologies include collateral failure, brain edema, seizures, reocclusion after successful initial therapeutic recanalization, and systemic medical complications. Clot propagation and recurrent embolization are only infrequent mechanisms of worsening. The advent of multimodal computed tomography and magnetic resonance imaging has transformed the evaluation of the deteriorating stroke patient. History, physical examination, screening blood work, and emergent reassessment of the cervical and cerebral vasculatures, regional hypoperfusion, and infarct core will yield a firm diagnosis of the cause of clinical worsening in the majority of patients. The therapeutic armamentarium for the worsening stroke patient has expanded greatly. Treatment options now include rescue late endovascular recanalization therapy, pressor collateral enhancement therapy, hemicraniectomy, and additional novel interventions in addition to enhanced supportive care. Because most causes of worsening can be treated effectively, the deteriorating stroke patient merits a swift and incisive diagnostic and therapeutic response.
Stenting of symptomatic intracranial atherosclerosis remains under investigation, yet this option to potentially avert subsequent stroke has been offered at select centers under humanitarian device ...exemption and off-label use for several years.
Retrospective case series of consecutive patients undergoing stenting with Wingspan and balloon mounted coronary stents for symptomatic intracranial atherosclerosis at a single institution. Recurrent symptomatic ischemia in the territory of the stented artery was ascertained. Rates of recurrent ischemic stroke were calculated per patient-year of follow-up and were compared with medically treated patients in the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial.
During the 10 year study period, 41 cases of intracranial stenting were identified. Stenoses were severe (>70%) in 88% of patients. Stenting procedures occurred a median of 14 days from the most recent symptomatic event. 19 Wingspan stents and 22 balloon mounted coronary stents were deployed. Four strokes occurred within 24 h of stenting, seven within 1 month and eight within 3 months. By 3 months after stenting, no further strokes occurred during up to 2 years of follow-up. Patients had 0.194 ischemic strokes per person-year of follow-up, compared with 0.083 ischemic strokes per person-year of follow-up in the aspirin arm of WASID and 0.065 ischemic strokes per person-year of follow-up in the warfarin arm of WASID.
Stenting of symptomatic intracranial atherosclerosis in a high risk subset of cases with advanced degree of luminal stenosis may be associated with an increased early risk of recurrent ischemic stroke.
OBJECTIVE:To analyze the dose–risk relationship for alcohol consumption and intracerebral hemorrhage (ICH) in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study.
METHODS:ERICH is ...a multicenter, prospective, case-control study, designed to recruit 1,000 non-Hispanic white patients, 1,000 non-Hispanic black patients, and 1,000 Hispanic patients with ICH. Cases were matched 1:1 to ICH-free controls by age, sex, race/ethnicity, and geographic area. Comprehensive interviews included questions regarding alcohol consumption. Patterns of alcohol consumption were categorized as none, rare (<1 drink per month), moderate (≥1 drink per month and ≤2 drinks per day), intermediate (>2 drinks per day and <5 drinks per day), and heavy (≥5 drinks per day). ICH risk was calculated using the no-alcohol use category as the reference group.
RESULTS:Multivariable analyses demonstrated an ordinal trend for alcohol consumptionrare (odds ratio OR 0.57, p < 0.0001), moderate (OR 0.65, p < 0.0001), intermediate (OR 0.82, p = 0.2666), and heavy alcohol consumption (OR 1.77, p = 0.0003). Subgroup analyses demonstrated an association of rare and moderate alcohol consumption with decreased risk of both lobar and nonlobar ICH. Heavy alcohol consumption demonstrated a strong association with increased nonlobar ICH risk (OR 2.04, p = 0.0003). Heavy alcohol consumption was associated with significant increase in nonlobar ICH risk in black (OR 2.34, p = 0.0140) and Hispanic participants (OR 12.32, p < 0.0001). A similar association was not found in white participants.
CONCLUSIONS:This study demonstrated potential protective effects of rare and moderate alcohol consumption on ICH risk. Heavy alcohol consumption was associated with increased ICH risk. Race/ethnicity was a significant factor in alcohol-associated ICH risk; heavy alcohol consumption in black and Hispanic participants poses significant nonlobar ICH risk.
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