To evaluate the frequency and outcome of haemorrhagic transformation (HT) after ischaemic stroke in patients treated with non-vitamin K antagonist oral anticoagulants (NOACs).
Patients with stroke on ...treatment with a NOAC were prospectively enrolled in this multicentre observational study between February 2012 and 2015. Brain imaging at admission and follow-up imaging until day 7 were reviewed for HT. Functional outcome was assessed by the modified Rankin scale (mRS) before the index event, at discharge, and at 3-months.
231 patients without recanalisation therapy (no-RT), and 32 patients with RT were eligible for analysis. Any HT was present at admission in 9/231 no-RT patients (3.9%, 95% CI 2.0 to 7.3) and in none of the patients with RT. In patients with follow-up imaging (no-RT, n=129, and RT, n=32), HT was present in 14.0% (no-RT; 95% CI, 8.9 to 21.1), and 40.6% (RT, 95% CI, 25.5 to 57.8), respectively. After adjustment for stroke severity, this difference between the no-RT and RT groups became non-significant. Symptomatic ICH was observed in 1 patient per group. HT was not associated with unfavourable outcome (mRS 3-6) at 3-months in multivariable analysis. Resumption of OAC after stroke was delayed in patients with HT compared to those without (15 d IQR, 5-26 vs. 1 d 0-4,
<0.001).
The frequency and severity of HT after stroke on NOAC appears similar to previous reports for vitamin K antagonists and no anticoagulation. Whether asymptomatic HT should delay resumption of preventive anticoagulation requires further investigation.
Abstract only Background: ATTICUS is the third prospective randomized controlled trial that compared a direct oral anticoagulant (DOAC) vs. acetylsalicylic acid (ASA) for secondary prevention after ...embolic stroke of undetermined source (ESUS). Aim of ATTICUS was to determine whether apixaban, initiated within 28 days after ESUS, is superior to ASA in preventing new ischemic lesions on 12-month follow- up MRI (primary endpoint) in subjects with remote atrial fibrillation (AF) monitoring. Methods: Multicenter (14 German centers) open-label randomized (1:1) controlled trial with blinded endpoint assessment. ESUS patients with at least one risk factor for AF/cardiac thromboembolism (i.e., left atrium (LA) size > 45 mm, spontaneous echo contrast in LA appendage, LA appendage flow velocity ≤ 0.2 m/s, atrial high-rate episodes, CHA2DS2-VASc ≥ 4, patent foramen ovale (PFO)) were enrolled. Study drug was initiated 3 to 28 days after minor/moderate stroke and ≥ 14 to 28 days after major stroke. ClinicalTrials.gov: NCT02427126. Funding by Bristol Meyers Squibb-Pfizer Alliance (Euro 2.2 Mio.) and Medtronic. Results: 352 patients were available for final analysis. New ischemic lesion(s) were found in 13.6% vs. 16.0% of patients in the apixaban and the ASA arm, respectively (p=0.57), intention-to-treat. AF was detected in 25.6 % of patients. No difference between study arms was found for other thromboembolism, death, SAE, major and clinically relevant bleeds. Conclusions: ATTICUS was the first trial testing the concept of DOAC vs. ASA in an enriched ESUS population. Mandatory cardiac monitoring, vessel imaging, and MRI in all ATTICUS patients will help to better understand this complex condition. We will present secondary analyses including on-treatment analysis, prevention of embolic/disabling lesions/strokes, association of stroke pattern with AF occurrence/macroangiopathic changes.
According to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification, embolic stroke of undetermined source (ESUS) has refined the old definition of cryptogenic stroke. More ...sophisticated criteria and a well-defined diagnostic workup point out the embolic nature of this disease. Because ESUS is associated with a high stroke recurrence, a clear risk prediction and management is of utmost importance to improve prognosis. To date, standard pharmacotherapy consists of antiplatelet drugs and statins. This review attempts to provide an overview on the diagnostic criteria, prognosis, and current clinical trials evaluating the value of direct oral anticoagulants for secondary prevention after ESUS.
Hyperbaric (HBO) or normobaric oxygen (NBO) therapy applied in acute ischemic stroke aims to increase oxygen supply to the ischemic tissue and to reduce the extent of irreversible tissue damage. Over ...the past decade, multiple studies have clarified the potential and limitations of oxygen therapy in preclinical stroke models. Considering that the reduction of the infarct size amounts to 30-40%, the cerebroprotection induced by HBO is moderate. In the experimental setting, the effective time window of HBO initiation is only a few hours. Higher pressures (2.5-3 ATA) are more effective. Even though oxygen therapy has some effectiveness in permanent cerebral ischemia without vascular recanalization, it appears more promising for bridging of a transient ischemic period until reperfusion of the penumbra takes place. Compared to HBO, the implementation of NBO to the clinical setting would be substantially less demanding. Although recent experimental NBO-studies are promising, significant effectiveness of NBO was only shown in transient cerebral ischemia and if started within a narrow time window of maximum 30 minutes. Some studies suggest that the effect of HBO is superior to NBO both during transient and permanent cerebral ischemia, even if treatment initiation is delayed. Limited experimental studies do not support an additive effect of a sequential combination of both therapies at present. While the therapeutic potential of oxygen therapy in ischemic stroke was considerably better defined over the past years, the underlying cerebroprotective mechanisms of oxygen therapy remain to be fully elucidated. Recent studies have demonstrated that physical oxygen therapy indeed improves oxygen supply of the ischemic penumbra as well as the cellular bioenergetic metabolism. Therefore, the mitochondria including their role in apoptotic cell death pathways as well as the modification of the cellular hypoxia sensor HIF-1alpha are considered as potential "downstream pathways" of oxygen therapy. Finally, its beneficial effects on the ischemic microcirculation suggest an important modification of various cell types within the neurovascular unit.
First, to determine the sensitivity and specificity of six stroke recognition scores in a single cohort to improve interscore comparability. Second, to test four stroke severity scores repurposed to ...recognise stroke in parallel.
Of 9154 emergency runs, 689 consecutive cases of preclinically 'suspected central nervous system disorder' admitted to the emergency room (ER) of the Heidelberg University Hospital were included in the validation cohort. Using data abstracted from the neurological ER medical reports, retrospective assessment of stroke recognition scores became possible for the Cincinnati Prehospital Stroke Scale (CPSS), Face Arm Speech Test (FAST), Los Angeles Prehospital Stroke Screen (LAPSS), Melbourne Ambulance Stroke Screen (MASS), Medic Prehospital Assessment for Code Stroke (Med PACS) and Recognition of Stroke in the Emergency Room score (ROSIER), and that of stroke severity scores became possible for the Kurashiki Prehospital Stroke Scale (KPSS), Los Angeles Motor Scale (LAMS) and shortened National Institutes of Health Stroke Scale (sNIHSS)-8/sNIHSS-5. Test characteristics were calculated using the hospital discharge diagnosis as the reference standard.
The CPSS and FAST had a sensitivity of 83% (95% CI 76 to 88) and 85% (78% to 90%) and a specificity of 69% (64% to 73%) and 68% (63% to 72%), respectively. The more complex LAPSS, MASS and Med PACS had a high specificity (92% to 98%) but low sensitivity (44% to 71%). In the ROSIER, sensitivity (80%, 73 to 85) and specificity (79%, 75 to 83) were similar. Test characteristics for KPSS, sNIHSS-8 and sNIHSS-5 were similar to the simple recognition scores (sensitivity 83% to 86%, specificity 60% to 69%). The LAMS offered only low sensitivity.
The simple CPSS and FAST scores provide good sensitivity for stroke recognition. More complex scores do not result in better diagnostic performance. Stroke severity scores can be repurposed to recognise stroke at the same time because test characteristics are comparable with pure stroke recognition scores. Particular shortcomings of the individual scores are discussed.
Current guidelines for spontaneous intracerebral hemorrhage (ICH) recommend maintaining cerebral perfusion pressure (CPP) between 50 and 70 mmHg, depending on the state of autoregulation. We ...continuously assessed dynamic cerebral autoregulation and the possibility of determination of an optimal CPP (CPPopt) in ICH patients. Associations between autoregulation, CPPopt and functional outcome were explored.
Intracranial pressure (ICP), mean arterial pressure (MAP) and CPP were continuously recorded in 55 patients, with 38 patients included in the analysis. The pressure reactivity index (PRx) was calculated as moving correlation between MAP and ICP. CPPopt was defined as the CPP associated with the lowest PRx values. CPPopt was calculated using hourly updated of 4 hour windows. The modified Rankin Scale (mRS) was assessed at 3 months and associations between PRx, CPPopt and outcomes were explored using Pearson correlation and Fisher's exact test. Multivariate stepwise logistic regression models were calculated including standard outcome predictors along with percentage of time with PRx >0.2 and percentage of time within the CPPopt range.
An overall PRx indicating impairment of pressure reactivity was found in 47% of patients (n = 18). The mean PRx and the time spent with a PRx > 0.2 significantly correlated with mRS at 3 months (r = 0.50, P = 0.002; r = 0.46, P = 0.004). CPPopt was calculable during 57% of the monitoring time. The median CPP was 78 mmHg, the median CPPopt 83 mmHg. Mortality was lowest in the group of patients with a CPP close to their CPPopt. However, for none of the CPPopt variables a significant association to outcome was found. The percentage of time with impaired autoregulation and hemorrhage volume were independent predictors for acceptable outcome (mRS 1 to 4) at three months.
Failure of pressure reactivity seems common following severe ICH and is associated with unfavorable outcome. Real-time assessment of CPPopt is feasible in ICH and might provide a tool for an autoregulation-oriented CPP management. A larger trial is needed to explore if a CPPopt management results in better functional outcomes.
Mobile stroke units: Beyond thrombolysis Krothapalli, Neeharika; Hasan, David; Lusk, Jay ...
Journal of the neurological sciences,
08/2024, Letnik:
463
Journal Article
Recenzirano
In the last decade, mobile stroke units (MSUs) have shown the potential to transform prehospital stroke care, marking a paradigm shift in delivering ultra-rapid thrombolysis and streamlining triage ...processes. These units bring acute stroke care directly to patients, significantly shortening treatment times. This review outlines the rationale for MSU care and discusses the potential applications beyond the original purpose of delivering thrombolysis, including large vessel occlusion detection, intracerebral hemorrhage management, and innovative forms of prehospital research.
•Mobile stroke units (MSUs) present opportunity to transform prehospital stroke care•Evolution of MSUs encompasses applications beyond intravenous thrombolysis•Novel applications include LVO detection, ICH management, and prehospital research•Versatility in expanding indication spectrum for cerebral emergencies beyond stroke
The underlying etiology of ischemic stroke remains unknown in up to 30% of patients.
This study explored the causal role of complicated (American Heart Association-lesion type VI) nonstenosing ...carotid artery plaques (CAPs) in cryptogenic stroke (CS).
CAPIAS (Carotid Plaque Imaging in Acute Stroke) is an observational multicenter study that prospectively recruited patients aged older than 49 years with acute ischemic stroke that was restricted to the territory of a single carotid artery on brain magnetic resonance imaging (MRI) and unilateral or bilateral CAP (≥2 mm, NASCET North American Symptomatic Carotid Endarterectomy Trial <70%). CAP characteristics were determined qualitatively and quantitatively by high-resolution, contrast-enhanced carotid MRI at 3T using dedicated surface coils. The pre-specified study hypotheses were that that the prevalence of complicated CAP would be higher ipsilateral to the infarct than contralateral to the infarct in CS and higher in CS compared with patients with cardioembolic or small vessel stroke (CES/SVS) as a combined reference group. Patients with large artery stroke (LAS) and NASCET 50% to 69% stenosis served as an additional comparison group.
Among 234 recruited patients, 196 had either CS (n = 104), CES/SVS (n = 79), or LAS (n = 19) and complete carotid MRI data. The prevalence of complicated CAP in patients with CS was significantly higher ipsilateral (31%) to the infarct compared with contralateral to the infarct (12%; p = 0.0005). Moreover, the prevalence of ipsilateral complicated CAP was significantly higher in CS (31%) compared with CES/SVS (15%; p = 0.02) and lower in CS compared with LAS (68%; p = 0.003). Lipid-rich and/or necrotic cores in ipsilateral CAP were significantly larger in CS compared with CES/SVS (p < 0.05).
These findings substantiate the role of complicated nonstenosing CAP as an under-recognized cause of stroke. (Carotid Plaque Imaging in Acute Stroke CAPIAS; NCT01284933).
IMPORTANCE: Patients with cerebral venous thrombosis (CVT) are at risk of recurrent venous thrombotic events (VTEs). Non–vitamin K oral anticoagulants have not been evaluated in randomized controlled ...trials in CVT. OBJECTIVE: To compare the efficacy and safety of dabigatran etexilate with those of dose-adjusted warfarin in preventing recurrent VTEs in patients who have experienced a CVT. DESIGN, SETTING, AND PARTICIPANTS: RE-SPECT CVT is an exploratory, prospective, randomized (1:1), parallel-group, open-label, multicenter clinical trial with blinded end-point adjudication (PROBE design). It was performed from December 21, 2016, to June 22, 2018, with a follow-up of 25 weeks, at 51 tertiary sites in 9 countries (France, Germany, India, Italy, the Netherlands, Poland, Portugal, Russia, and Spain). Adult consecutive patients with acute CVT, who were stable after 5 to 15 days of treatment with parenteral heparin, were screened for eligibility. Patients with CVT associated with central nervous system infection or major trauma were excluded, but those with intracranial hemorrhage from index CVT were allowed to participate. After exclusions, 120 patients were randomized. Data were analyzed following the intention-to-treat approach. INTERVENTIONS: Dabigatran, 150 mg twice daily, or dose-adjusted warfarin for a treatment period of 24 weeks. MAIN OUTCOMES AND MEASURES: Primary outcome was a composite of patients with a new VTE (recurrent CVT, deep vein thrombosis of any limb, pulmonary embolism, and splanchnic vein thrombosis) or major bleeding during the study period. Secondary outcomes were cerebral venous recanalization and clinically relevant non–major bleeding events. RESULTS: In total, 120 patients with CVT were randomized to the 2 treatment groups (60 to dabigatran and 60 to dose-adjusted warfarin). Of the randomized patients, the mean (SD) age was 45.2 (13.8) years, and 66 (55.0%) were women. The mean (SD) duration of exposure was 22.3 (6.16) weeks for the dabigatran group and 23.0 (5.20) weeks for the warfarin group. No recurrent VTEs were observed. One (1.7%; 95% CI, 0.0-8.9) major bleeding event (intestinal) was recorded in the dabigatran group, and 2 (3.3%; 95% CI, 0.4-11.5) (intracranial) in the warfarin group. One additional patient (1.7; 95% CI, 0.0-8.9) in the warfarin group experienced a clinically relevant non–major bleeding event. Recanalization occurred in 33 patients in the dabigatran group (60.0%; 95% CI, 45.9-73.0) and in 35 patients in the warfarin group (67.3%; 95% CI, 52.9-79.7). CONCLUSIONS AND RELEVANCE: This trial found that patients who had CVT anticoagulated with either dabigatran or warfarin had low risk of recurrent VTEs, and the risk of bleeding was similar with both medications, suggesting that both dabigatran and warfarin may be safe and effective for preventing recurrent VTEs in patients with CVT. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02913326
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