Aims/Introduction
Diabetes mellitus is an established risk factor for stroke and maybe associated with poorer outcomes after stroke. The aims of the present literature review were to determine: (i) ...the prevalence of diabetes in acute stroke patients through a meta‐analysis; (ii) the association between diabetes and outcomes after ischemic and hemorrhagic stroke; and (iii) to review the value of glycated hemoglobin and admission glucose‐based tests in predicting stroke outcomes.
Materials and Methods
Ovid MEDLINE and EMBASE searches were carried out to find studies relating to diabetes and inpatient stroke populations published between January 2004 and April 2017. A meta‐analysis of the prevalence of diabetes from included studies was undertaken. A narrative review on the associations of diabetes and different diagnostic methods on stroke outcomes was carried out.
Results
A total of 66 eligible articles met inclusion criteria. A meta‐analysis of 39 studies (n = 359,783) estimated the prevalence of diabetes to be 28% (95% confidence interval 26–31). The rate was higher in ischemic (33%, 95% confidence interval 28–38) compared with hemorrhagic stroke (26%, 95% confidence interval 19–33) inpatients. Most, but not all, studies found that acute hyperglycemia and diabetes were associated with poorer outcomes after ischemic or hemorrhagic strokes: including higher mortality, poorer neurological and functional outcomes, longer hospital stay, higher readmission rates, and stroke recurrence. Diagnostic methods for establishing diagnosis were heterogeneous between the reviewed studies.
Conclusions
Approximately one‐third of all stroke patients have diabetes. Uniform methods to screen for diabetes after stroke are required to identify individuals with diabetes to design interventions aimed at reducing poor outcomes in this high‐risk population.
Diabetes affects up to one‐third of stroke inpatients and has been found to be associated with poorer outcomes after stroke. There is heterogeneity in the diagnostic methods of diabetes between current studies examining the effects of diabetes on stroke outcomes.
In patients with cryptogenic stroke, undetected paroxysmal atrial fibrillation may be a cause of the stroke. In this randomized trial, an insertable cardiac monitor was superior to conventional ...cardiac monitoring for detecting atrial fibrillation in patients with cryptogenic stroke.
Ischemic stroke is among the leading causes of death and disability.
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The cause remains unexplained after routine evaluation in 20 to 40% of cases, resulting in the classification, by exclusion, of cryptogenic stroke.
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Atrial fibrillation is a well-recognized cause of ischemic stroke,
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though the risk is markedly reduced by anticoagulation
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Documentation of atrial fibrillation is required to initiate anticoagulant therapy after ischemic stroke.
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In the absence of documented atrial fibrillation, antiplatelet agents are recommended.
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Given the often paroxysmal and asymptomatic nature of atrial fibrillation, it may not be detected with the use of traditional monitoring techniques.
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Strategies . . .
Multiple studies evaluated whether patent foramen ovale (PFO) closure reduces the risk of ischemic stroke. One commonly reported complication of PFO closure is the development of atrial fibrillation ...(AF), which is itself a powerful stroke risk factor that requires specific management. This study aims to evaluate the frequency of AF in patients post-percutaneous closure of PFO and the clinical factors that predict AF detection.
Studies were identified by systematically searching EMBASE and MEDLINE databases on July 11, 2019. Meta-analysis of proportions was performed, assuming a random-effects model.
A total of 6 randomized controlled trials and 26 observational studies were included, comprising 3737 and 9126 patients, respectively. After PFO closure, the rate of AF development was 3.7 patients per 100 patient-years of follow-up (95% CI, 2.6–4.9). The risk of AF development is concentrated in the first 45 days post-procedure (27.2 patients per 100 patient-years 95% CI, 20.1–34.81, compared with 1.3 patients per 100 patient-years 95% CI, 0.3–2.7) after 45 days. Meta-regression by age suggested that studies with older patients reported higher rate of AF (P=0.001).In medically treated patients, the rate of AF development was 0.1 per 100 patient-years of follow-up (95% CI, 0.0–0.4). Closure of PFO is associated with increased risk of AF compared with medical management (odds ratio, 5.3 95% CI, 2.5–11.41; P<0.001).
AF is more common in PFO patients who had percutaneous closure compared with those who were medically treated. The risk of AF was higher in the first 45 days post-closure and in studies that included patients with increased age.
The Third European Cooperative Acute Stroke Study (ECASS-3) demonstrated a benefit of treatment with intravenous tissue plasminogen activator (tPA) for acute stroke in the 3- to 4.5-hour time-window. ...Prior studies, however, have failed to demonstrate a significant benefit of tPA for patients treated beyond 3 hours. The purpose of this study was to produce reliable and precise estimates of the treatment effect of tPA by pooling data from all relevant studies.
A metaanalysis was undertaken to determine the efficacy of tPA in the 3- to 4.5-hour time-window. The effect of tPA on favorable outcome and mortality was assessed.
The metaanalysis included data from patients treated in the 3- to 4.5-hour time-window in ECASS-1 (n=234), ECASS-2 (n=265), ECASS-3 (n=821) and The Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS) (n=302). tPA treatment was associated with an increased chance of favorable outcome (odds ratio 1.31; 95% CI: 1.10 to 1.56; P=0.002) and no significant difference in mortality (odds ratio 1.04; 95% CI: 0.75 to 1.43; P=0.83) compared to placebo treated patients.
Treatment with tPA in the 3- to 4.5-hour time-window is beneficial. It results in an increased rate of favorable outcome without adversely affecting mortality.
Background
Anticoagulants are recommended to prevent cardioembolic stroke in most patients with atrial fibrillation (AF). Management errors with anticoagulation and use of aspirin instead of ...anticoagulants have been documented worldwide, especially with vitamin K antagonists.
Aims
To assess the rate of anticoagulant mismanagement errors in patients admitted with ischaemic stroke and the clinical correlates with stroke outcomes in the era of non‐vitamin K oral anticoagulants.
Methods
We performed a retrospective analysis of patients admitted with ischaemic stroke and history of AF to a single‐centre tertiary hospital stroke unit in Melbourne, Australia, between January 2016 and June 2019. We assessed management errors as defined using European Heart Rhythm Association criteria with anticoagulation in the 2 weeks prior to the index stroke.
Results
A total of 306 patients with AF and ischaemic stroke was included, of whom 196 (64%) had management errors. Patients with management errors were older (median age 84 vs 81 years; P = 0.002) and more often female (53% vs 38%; P = 0.02). Of those with management errors, 74 (37%) were not prescribed any anticoagulation despite increased stroke risk and absence of contraindications and 40 (20%) had anticoagulation inappropriately ceased. Mortality at 3 months was 32% in those with management errors, compared with 17% in the appropriately anticoagulated group (P = 0.005).
Conclusions
Inappropriate management of anticoagulants is present in the majority of acute ischaemic stroke in the 2 weeks preceding the event and is linked to higher mortality. Improved anticoagulation practice has the potential to substantially reduce stroke rates in patients with AF.
ObjectivesTo examine the personal and social experiences of younger adults after stroke.DesignQualitative study design involving in-depth semi-structured interviews and rigorous qualitative ...descriptive analysis informed by social constructionism.ParticipantsNineteen younger stroke survivors aged 18 to 55 years at the time of their first-ever stroke.SettingParticipants were recruited from urban and rural settings across Australia. Interviews took place in a clinic room of the Florey Institute of Neuroscience and Mental Health (Melbourne, Australia), over an online conference platform or by telephone.ResultsFour main themes emerged from the discourses: (1) psycho-emotional experiences after young stroke; (2) losing pre-stroke life construct and relationships; (3) recovering and adapting after young stroke; and (4) invalidated by the old-age, physical concept of stroke. While these themes ran through the narratives of all participants, data analysis also drew out interesting variation between individual experiences.ConclusionsFor many younger adults, stroke is an unexpected and devastating life event that profoundly diverts their biography and presents complex and continued challenges to fulfilling age-normative roles. While adaptation, resilience and post-traumatic growth are common, this study suggests that more bespoke support is needed for younger adults after stroke. Increasing public awareness of young stroke is also important, as is increased research attention to this problem.
The discovery of thrombolytic agents goes back to the 1930s, when it was shown that substances derived from bacteria (streptokinase, staphylokinase), tissue (fibrinokinase), urine (urokinase) or bat ...saliva could activate the fibrinolytic system. The potential to treat arterial thrombosis with plasmin was recognized, but it was not until 1958 that its first use in acute ischaemic stroke (AIS) was described. However, since computer tomography (CT) was not available until the mid 1970s, optimal selection of patients was not possible. Early studies with streptokinase in AIS showed an increased risk of intracranial haemorrhage and lack of efficacy, which was associated with low fibrin specificity. The search for new agents with a better risk-benefit profile continued until 1979 when tissue plasminogen activator (t-PA) was discovered. In 1983 it became possible to produce recombinant t-PA (rt-PA) by expression of a cloned gene which enabled clinical trials to be started, mainly for coronary thrombolysis. In 1995, the National Institute of Neurological Disorders and Stroke study showed that rt-PA was an effective treatment for AIS, nowadays for use up to 4.5 h after onset. However, rt-PA still often fails in achieving rapid reperfusion, has relatively low recanalization rates and is associated with an increased bleeding risk. Several attempts have been made to develop thrombolytics with a better risk-benefit profile than rt-PA, but no real impact on clinical practice was observed. In 1994, it was shown that tenecteplase (rt-PA-TNK) had a higher fibrin specificity than rt-PA, but its clinical use in AIS was described only in 2005. The recently reported results of a small phase 2B trial showed significantly better reperfusion and clinical outcome with rt-PA-TNK compared to rt-PA; patients were selected by CT perfusion and angiography, and treated within 6 h after stroke onset. Currently, a phase 3 trial of rt-PA-TNK versus rt-PA is being planned in patients at an onset up to 4.5 h. The most fibrin-specific recombinant plasminogen activator desmoteplase originates from 1991, and its clinical development in AIS started in 2005. Desmoteplase is in phase 3 development for the treatment of AIS between 3 and 9 h after onset in AIS patients presenting with occlusion or high-grade stenosis.
The association between somatosensory impairments and outcome after stroke remains unclear.
The aim of this study was to systematically review the available literature on the relationship between ...somatosensory impairments in the upper limb and outcome after stroke.
The electronic databases PubMed, CINAHL, EMBASE, Cochrane Library, PsycINFO, and Web of Science were systematically searched from inception until July 2013.
Studies were included if adult patients with stroke (minimum n=10) were examined with reliable and valid measures of somatosensation in the upper limb to investigate the relationship with upper limb impairment, activity, and participation measures. Exclusion criteria included measures of somatosensation involving an overall score for upper and lower limb outcome and articles including only lower limb outcomes.
Eligibility assessment, data extraction, and quality evaluation were completed by 2 independent reviewers. A cutoff score of ≥65% of the maximal quality score was used for further inclusion in this review.
Six articles met all inclusion criteria. Two-point discrimination was shown to be predictive for upper limb dexterity, and somatosensory evoked potentials were shown to have predictive value in upper limb motor recovery. Proprioception was significantly correlated with perceived level of physical activity and social isolation and had some predictive value in functional movements of the upper limb. Finally, the combination of light touch and proprioception impairment was shown to be significantly related to upper limb motor recovery as well as handicap situations during activities of daily living.
Heterogeneity of the included studies warrants caution when interpreting results.
Large variation in results was found due to heterogeneity of the studies. However, somatosensory deficits were shown to have an important role in upper limb motor and functional performance after stroke.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
BACKGROUND AND PURPOSE—We sought to assess whether the volume of the ischemic penumbra can be estimated more accurately by altering the threshold selected for defining perfusion-weighting imaging ...(PWI) lesions.
METHODS—DEFUSE is a multicenter study in which consecutive acute stroke patients were treated with intravenous tissue-type plasminogen activator 3 to 6 hours after stroke onset. Magnetic resonance imaging scans were obtained before, 3 to 6 hours after, and 30 days after treatment. Baseline and posttreatment PWI volumes were defined according to increasing Tmax delay thresholds (>2, >4, >6, and >8 seconds). Penumbra salvage was defined as the difference between the baseline PWI lesion and the final infarct volume (30-day fluid-attenuated inversion recovery sequence). We hypothesized that the optimal PWI threshold would provide the strongest correlations between penumbra salvage volumes and various clinical and imaging-based outcomes.
RESULTS—Thirty-three patients met the inclusion criteria. The correlation between infarct growth and penumbra salvage volume was significantly better for PWI lesions defined by Tmax >6 seconds versus Tmax >2 seconds, as was the difference in median penumbra salvage volume in patients with a favorable versus an unfavorable clinical response. Among patients who did not experience early reperfusion, the Tmax >4 seconds threshold provided a more accurate prediction of final infarct volume than the >2 seconds threshold.
CONCLUSIONS—Defining PWI lesions based on a stricter Tmax threshold than the standard >2 seconds delay appears to provide more a reliable estimate of the volume of the ischemic penumbra in stroke patients imaged between 3 and 6 hours after symptom onset. A threshold between 4 and 6 seconds appears optimal for early identification of critically hypoperfused tissue.
Objective
To determine whether prespecified baseline magnetic resonance imaging (MRI) profiles can identify stroke patients who have a robust clinical response after early reperfusion when treated 3 ...to 6 hours after symptom onset.
Methods
We conducted a prospective, multicenter study of 74 consecutive stroke patients admitted to academic stroke centers in North America and Europe. An MRI scan was obtained immediately before and 3 to 6 hours after treatment with intravenous tissue plasminogen activator 3 to 6 hours after symptom onset. Baseline MRI profiles were used to categorize patients into subgroups, and clinical responses were compared based on whether early reperfusion was achieved.
Results
Early reperfusion was associated with significantly increased odds of achieving a favorable clinical response in patients with a perfusion/diffusion mismatch (odds ratio, 5.4; p = 0.039) and an even more favorable response in patients with the Target Mismatch profile (odds ratio, 8.7; p = 0.011). Patients with the No Mismatch profile did not appear to benefit from early reperfusion. Early reperfusion was associated with fatal intracranial hemorrhage in patients with the Malignant profile.
Interpretation
For stroke patients treated 3 to 6 hours after onset, baseline MRI findings can identify subgroups that are likely to benefit from reperfusion therapies and can potentially identify subgroups that are unlikely to benefit or may be harmed. Ann Neurol 2006
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