Objective
Emerging data indicate an increased risk of cerebrovascular events with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) and highlight the potential impact of coronavirus ...disease (COVID‐19) on the management and outcomes of acute stroke. We conducted a systematic review and meta‐analysis to evaluate the aforementioned considerations.
Methods
We performed a meta‐analysis of observational cohort studies reporting on the occurrence and/or outcomes of patients with cerebrovascular events in association with their SARS‐CoV‐2 infection status. We used a random‐effects model. Summary estimates were reported as odds ratios (ORs) and corresponding 95% confidence intervals (CIs).
Results
We identified 18 cohort studies including 67,845 patients. Among patients with SARS‐CoV‐2, 1.3% (95% CI = 0.9–1.6%, I2 = 87%) were hospitalized for cerebrovascular events, 1.1% (95% CI = 0.8–1.3%, I2 = 85%) for ischemic stroke, and 0.2% (95% CI = 0.1–0.3%, I2 = 64%) for hemorrhagic stroke. Compared to noninfected contemporary or historical controls, patients with SARS‐CoV‐2 infection had increased odds of ischemic stroke (OR = 3.58, 95% CI = 1.43–8.92, I2 = 43%) and cryptogenic stroke (OR = 3.98, 95% CI = 1.62–9.77, I2 = 0%). Diabetes mellitus was found to be more prevalent among SARS‐CoV‐2 stroke patients compared to noninfected historical controls (OR = 1.39, 95% CI = 1.00–1.94, I2 = 0%). SARS‐CoV‐2 infection status was not associated with the likelihood of receiving intravenous thrombolysis (OR = 1.42, 95% CI = 0.65–3.10, I2 = 0%) or endovascular thrombectomy (OR = 0.78, 95% CI = 0.35–1.74, I2 = 0%) among hospitalized ischemic stroke patients during the COVID‐19 pandemic. Odds of in‐hospital mortality were higher among SARS‐CoV‐2 stroke patients compared to noninfected contemporary or historical stroke patients (OR = 5.60, 95% CI = 3.19–9.80, I2 = 45%).
Interpretation
SARS‐CoV‐2 appears to be associated with an increased risk of ischemic stroke, and potentially cryptogenic stroke in particular. It may also be related to an increased mortality risk. ANN NEUROL 2021;89:380–388
Background and purpose
Measurement of the cross‐sectional area (CSA) of peripheral nerves using ultrasound is useful in the evaluation of focal lesions like entrapment syndromes and inflammatory ...polyneuropathies. Here, a systematic review and meta‐analysis of published CSA reference values for upper extremity nerves was performed.
Methods
Available to date nerve ultrasound studies on healthy adults were included and a meta‐analysis for CSA was provided of the following nerves: median nerve at the wrist, forearm, upper arm; ulnar nerve at the Guyon's canal, forearm, elbow, upper arm; radial nerve at the upper arm. Regression and correlation analyses for age, gender, height, weight, geographic continents and publication year are reported.
Results
Seventy‐four studies with 4186 healthy volunteers (mean age 42.7 years) and 18,226 examined nerve sites were included. The calculated mean pooled CSA of the median nerve at the wrist was 8.3 mm2 (95% confidence interval 95% CI 7.9–8.7, n = 4071), at the forearm 6.4 mm2 (95% CI 5.9–6.9, n = 3021), at the upper arm 8.3 mm2 (95% CI 7.5–9.0, n = 1388), of the ulnar nerve at the Guyon's canal 4.1 mm2 (95% CI 3.6–4.6, n = 1688), at the forearm 5.2 mm2 (95% CI 4.8–5.7, n = 1983), at the elbow 5.9 mm2 (95% CI 5.4–6.5, n = 2551), at the upper arm 6.6 mm2 (95% CI 5.1–6.1, n = 1737) and of the radial nerve 5.1 mm2 (95% CI 4.0–6.2, n = 1787). Substantial heterogeneity across studies (I2 > 50%) was found only for the radial nerve. Subgroup analysis revealed a positive effect of age for the median nerve at the wrist and for height and weight for different sites of the ulnar nerve.
Conclusion
The first meta‐analysis on CSA reference values for the upper extremities with no or only low heterogeneity of reported CSA values in most nerve sites is provided. Our data facilitate the goal of an international standardized evaluation protocol.
Reference values for cross‐sectional area (CSA) of peripheral nerve ultrasound were published from several authors with varying heterogeneity. Here, the first meta‐analysis on CSA reference values for the upper extremities with no or only low heterogeneity of reported CSA values in most nerve sites is provided.
Ischemic strokes related to atrial fibrillation are highly prevalent, presenting with severe neurologic syndromes and associated with high risk of recurrence. Although advances have been made in both ...primary and secondary stroke prevention for patients with atrial fibrillation, the long-term risks for stroke recurrence and bleeding complications from antithrombotic treatment remain substantial. We summarize the major advances in stroke prevention for patients with atrial fibrillation during the past 30 years and focus on novel diagnostic and treatment approaches currently under investigation in ongoing clinical trials. Non-vitamin K antagonist oral anticoagulants have been proven to be safer and equally effective compared with warfarin in stroke prevention for patients with nonvalvular atrial fibrillation. Non-vitamin K antagonist oral anticoagulants are being investigated for the treatment of patients with atrial fibrillation and rheumatic heart disease, for the treatment of patients with recent embolic stroke of undetermined source and indirect evidence of cardiac embolism, and in the prevention of vascular-mediated cognitive decline in patients with atrial fibrillation. Multiple clinical trials are assessing the optimal timing of non-vitamin K antagonist oral anticoagulant initiation after a recent ischemic stroke and the benefit:harm ratio of non-vitamin K antagonist oral anticoagulant treatment in patients with atrial fibrillation and history of previous intracranial bleeding. Ongoing trials are addressing the usefulness of left atrial appendage occlusion in both primary and secondary stroke prevention for patients with atrial fibrillation, including those with high risk of bleeding. The additive value of prolonged cardiac monitoring for subclinical atrial fibrillation detection through smartphone applications or implantable cardiac devices, together with the optimal medical management of individuals with covert paroxysmal atrial fibrillation, is a topic of intensive research interest. Colchicine treatment and factor XIa inhibition constitute 2 novel pharmacologic approaches that might provide future treatment options in the secondary prevention of cardioembolic stroke attributable to atrial fibrillation.
In 2006, the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial1 showed the benefit of intensive statin treatment (atorvastatin 80 mg daily) in secondary stroke ...prevention. Almost 15 years later, the effect of intensive reduction of LDL cholesterol after a recent ischaemic stroke or transient ischaemic attack in the setting of atherosclerotic disease was assessed in the Treat Stroke to Target trial,2 a parallel group, single-blind, randomised trial done at 77 sites in France and South Korea. Taking into account the 20% wide non-inferiority margin with respect to functional outcome, the difference between groups in the percentages of enrolled patients not receiving endovascular thrombectomy, and the many patients allocated combination treatment who did not receive the full dose of alteplase, in addition to the fact that alteplase is not reimbursed in China, this research question still remains open and will hopefully be answered soon by other ongoing randomised trials.7 Although endovascular thrombectomy has substantially improved functional outcomes of patients with acute ischaemic stroke, many treated individuals die or are left severely disabled.
Background and purpose
Measurement of the cross‐sectional area (CSA) of peripheral nerves using ultrasound is useful in the evaluation of focal lesions such as entrapment syndromes and inflammatory ...polyneuropathies. We performed a systematic review and meta‐analysis of published CSA reference values for lower extremity nerves.
Methods
We included available‐to‐date nerve ultrasound studies on healthy adults and provide meta‐analysis for CSA of the following nerves: fibular nerve at fibular head, popliteal fossa; tibial nerve at popliteal fossa, malleolus; and sural nerve at the level of the two heads of gastrocnemius muscle. We report regression and correlation analyses for age, gender distribution, height, weight, and geographic continent.
Results
We included 16 studies with 1001 healthy volunteers (mean age = 47.9 years) and 4023 examined nerve sites. Calculated mean pooled CSA of fibular nerve at fibular head was 8.4 mm2 (95% confidence interval CI = 6.8–9.9 mm2, n = 1166), at popliteal fossa was 7.9 mm2 (95% CI = 6.6–9.2 mm2, n = 995), of tibial nerve at popliteal fossa was 25.9 mm2 (95% CI = 17.5–34.4 mm2, n = 771), at malleolus was 10.0 mm2 (95% CI = 7.7–12.4 mm2, n = 779), and of sural nerve was 2.4 mm2 (95% CI = 1.7–3.1 mm2, n = 312). Substantial heterogeneity across studies (I2 > 50%) was found only for tibial nerve at popliteal fossa. Subgroup analysis revealed a lower CSA of tibial nerve at popliteal fossa and sural nerve in studies conducted in Europe than in North America and New Zealand.
Conclusions
We provide the first meta‐analysis on CSA reference values for the lower extremities with no or low heterogeneity of reported CSA values in all nerve sites except tibial nerve at popliteal fossa. Our data facilitate the goal of an international standardized evaluation protocol.
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