Purpose
Acute central retinal artery occlusion (CRAO) induces ischaemic retinal oedema. The purpose of this study was to define sensitivity and specificity of optical coherence tomography (OCT) based ...retinal thickness analysis in determining ischaemia onset in CRAO.
Methods
The relative retinal thickness increase (RRTI) in comparison with the fellow eye was analysed retrospectively in OCT scans of 66 patients diagnosed with CRAO between January 2010 and December 2019 within 48 hr of ischaemia onset. The natural course of RRTI and the sensitivity and specificity of OCT‐based determination of ischaemia onset in identifying CRAO within 4.5 hr using the RRTI were evaluated.
Results
Relative retinal thickness increase (RRTI) in acute CRAO follows a hyperbolic curve with a steep incline within the early phase after which it reaches a plateau. Optical coherence tomography (OCT)‐based retinal thickness analysis in CRAO allows to differentiate patients with ischaemia onset within the past 4.5 hr or thereafter with a sensitivity of 100% and a specificity of 94.3%.
Conclusion
Relative retinal thickness increase (RRTI) allows to identify CRAO patients that are eligible for a potentially beneficial reperfusion therapy within a therapeutic window of 4.5 hr with a high accuracy. Especially in patients with unknown ischaemia onset, this diagnostic tool could be of major importance in the future clinical management.
Abstract only Introduction: Migraine is a risk factor for cerebral ischemic stroke. However, it is not known if migraine is a risk factor for retinal stroke (central retinal artery occlusion, CRAO). ...Methods: We performed a retrospective cohort study using population-based data from the State Inpatient Databases and State Emergency Department Databases from New York (2006-2015), California (2003-2011), and Florida (2005-2015) to determine the association between hospital-documented migraine and retinal stroke. The primary exposure was hospital-documented migraine. The primary endpoint was hospital-documented CRAO (ICD-9-CM code 362.31 in the primary diagnosis position) and secondary endpoints included BRAO and any retinal artery occlusion (RAO). Cause-specific hazard models were used to model the association between migraine and CRAO. Results: Of 39,835,024 patients included in the study, 1,109,140 had migraine documented during the exposure window. Patients with migraine were younger (40.2±15.2 vs. 46.9±19.8, standardized difference (SD) 0.38), more likely to be female (81.4% vs. 54.7%, SD 0.6), and had a lower burden of atrial fibrillation (4.5% vs. 6.9%, SD 0.1), chronic kidney disease (1.9% vs. 3.6%, SD 0.2), and congestive cardiac failure (2.7% vs. 5.1%, SD 0.12). Migraine was not associated with CRAO in the primary diagnostic position (adjusted hazard rate (aHR) 1.15 (95% CI: 0.79-1.67). However, it was associated with CRAO in any diagnostic position (aHR 1.39 (95% CI: 1.08-1.78). As positive controls, we replicated previously established associations of migraine with cerebral ischemic stroke (aHR 1.35 (95% CI: 1.32-1.38) and embolic ischemic stroke (aHR 1.15 (95% CI: 1.08-1.22). Conclusions: In a large, claims-based study, we found a risk-adjusted association between migraine and CRAO considered in any diagnostic position. This finding sets the stage for future work leveraging both outpatient and pharmacy-based claims to further explore this finding.
Objectives: Prediction of large vessel occlusion (LVO) is highly relevant for accurate prehospital transportation triage. The Austrian Prehospital Stroke Scale (APSS) score for LVO prediction was ...developed using critical synthesis of previously published LVO-scores. The aim of this study was to investigate the accuracy of the APSS and compare it to other LVO-scores. Methods: APSS consists of 5 items: "facial palsy," "motor arm," "language," "motor leg" and "gaze deviation." The score ranges from 0 to 9 points. Data from 741 consecutive stroke patients with acute vessel imaging admitted to an independent comprehensive stroke center was used to test the predictive performance of the APSS in context of other LVO-scores (CPSS, FAST-ED, G-FAST, sNIHSS-EMS and RACE). Results: In the prediction of treatable LVO the APSS showed the highest area under the curve (0.834) with significant difference to CPSS (p = 0.010) and G-FAST (p = 0.006) and showed highest sensitivity (69%) as compared to other LVO scores. Specificity (85%), positive predictive value (75%), negative predictive value (81%) and accuracy (79%) were comparable to other LVO scores. Receiver operating curve analysis revealed an optimal cutoff for LVO prediction at APSS equal to 4 points. Conclusions: The easy assessable 5-item APSS score tended to outperform other LVO scores. Real-life prospective evaluation in prehospital setting is ongoing.
Abstract
Major bleeding is a common threat in patients requiring antiplatelet therapy. Timing and intensity with regard to resumption of antiplatelet therapy represent a major challenge in clinical ...practice. Knowledge of the patient's bleeding risk, defining transient/treatable and permanent/untreatable risk factors for bleeding, and weighing these against thrombotic risk are key to successful prevention of major adverse events. Shared decision-making involving various disciplines is essential to determine the optimal strategy. The present article addresses clinically relevant questions focusing on the most life-threatening or frequently occurring bleeding events, such as intracranial hemorrhage and gastrointestinal bleeding, and discusses the evidence for antiplatelet therapy resumption using individual risk assessment in high-risk cardiovascular disease patients.
Point-of-care testing (POCT) of coagulation has been proven to be of great value in accelerating emergency treatment. Specific POCT for direct oral anticoagulants (DOAC) is not available, but the ...effects of DOAC on established POCT have been described. We aimed to determine the diagnostic accuracy of Hemochron® Signature coagulation POCT to qualitatively rule out relevant concentrations of apixaban, rivaroxaban, and dabigatran in real-life patients.
We enrolled 68 patients receiving apixaban, rivaroxaban, or dabigatran and obtained blood samples at six pre-specified time points. Coagulation testing was performed using prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), and activated clotting time (ACT+ and ACT-low range) POCT cards. For comparison, laboratory-based assays of diluted thrombin time (Hemoclot) and anti-Xa activity were conducted. DOAC concentrations were determined by liquid chromatography-tandem mass spectrometry.
Four hundred and three samples were collected. POCT results of PT/INR and ACT+ correlated with both rivaroxaban and dabigatran concentrations. Insufficient correlation was found for apixaban. Rivaroxaban concentrations at <30 and <100 ng/mL were detected with >95% specificity at PT/INR POCT ≤1.0 and ≤1.1 and ACT+ POCT ≤120 and ≤130 s. Dabigatran concentrations at <30 and <50 ng/mL were detected with >95% specificity at PT/INR POCT ≤1.1 and ≤1.2 and ACT+ POCT ≤100 s.
Hemochron® Signature POCT can be a fast and reliable alternative for guiding emergency treatment during rivaroxaban and dabigatran therapy. It allows the rapid identification of a relevant fraction of patients that can be treated immediately without the need to await the results of much slower laboratory-based coagulation tests.
Unique identifier, NCT02371070 . Retrospectively registered on 18 February 2015.
Objective
Approximately 20% of strokes are embolic strokes of undetermined source (ESUS). Undetected atrial fibrillation (AF) remains an important cause. Yet, oral anticoagulation in unselected ESUS ...patients failed in secondary stroke prevention. Guidance on effective AF detection is lacking. Here, we introduce a novel, non‐invasive AF risk assessment after ESUS.
Methods
Catch‐Up ESUS is an investigator‐initiated, observational cohort study conducted between 2018 and 2019 at the Munich University Hospital. Besides clinical characteristics, patients received ≥72 h digital electrocardiogram recordings to generate the rhythm irregularity burden. Uni‐ and multivariable regression models predicted the primary endpoint of incident AF, ascertained by standardized follow‐up including implantable cardiac monitors. Predictors included the novel rhythm irregularity burden constructed from digital electrocardiogram recordings. We independently validated our model in ESUS patients from the University Hospital Tübingen, Germany.
Results
A total of 297 ESUS patients were followed for 15.6 ± 7.6 months. Incident AF (46 patients, 15.4%) occurred after a median of 105 days (25th to 75th percentile 31–33 days). Secondary outcomes were recurrent stroke in 7.7% and death in 6.1%. Multivariable‐adjusted analyses identified the rhythm irregularity burden as the strongest AF‐predictor (hazard ratio 3.12, 95% confidence interval 1.62–5.80, p < 0001) while accounting for the known risk factors age, CHA2DS2‐VASc‐Score, and NT‐proBNP. Independent validation confirmed the rhythm irregularity burden as the most significant AF‐predictor (hazard ratio 2.20, 95% confidence interval 1.45–3.33, p < 0001).
Interpretation
The novel, non‐invasive, electrocardiogram‐based rhythm irregularity burden may help adjudicating AF risk after ESUS, and subsequently guide AF‐detection after ESUS. Clinical trials need to clarify if high‐AF risk patients benefit from tailored secondary stroke prevention. ANN NEUROL 2023;93:479–488
The results of our study cannot be used to explain a dose-dependent association with thromboembolism because most of the patients in the FFP group received PCC after 3 h. Our findings are in accord ...with findings from other studies of vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions or in patients with ICH.3,4 We agree that more data are needed to confirm the clinical benefit of PCC for VKA-ICH. ...in view of the other clinical trials investigating a potential benefit of haemostatic agents or blood pressure reduction in spontaneous ICH, another trial on VKA-ICH with a clinical endpoint would need a very large number of patients, and some experts might question the ethical justification after the results of our proof-of-concept trial.
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