BACKGROUND AND PURPOSE:Diabetic retinopathy (DR) is a common microvascular complication of diabetes, which causes damage to the retina and may lead to rapid vision loss. Previous research has shown ...that the macrovascular complications of diabetes, including stroke, are often comorbid with DR. We sought to explore the association between DR and subsequent stroke events.
METHODS:This is a secondary analysis of patients enrolled in the ACCORD Eye study (Action to Control Cardiovascular Risk in Diabetes). The primary outcome was stroke during follow-up. The exposure was presence of DR at study baseline. We fit adjusted Cox proportional hazards models to provide hazard ratios for stroke and included interaction terms with the ACCORD randomization arms.
RESULTS:We included 2828 patients, in whom the primary outcome of stroke was met by 117 (4.1%) patients during a mean (SD) of 5.4 (1.8) years of follow-up. DR was present in 874 of 2828 (30.9%) patients at baseline and was more common in patients with than without incident stroke (41.0% versus 30.5%; P=0.016). In an adjusted Cox regression model, DR was independently associated with incident stroke (hazard ratio, 1.52 95% CI, 1.05–2.20; P=0.026). This association was not affected by randomization arm in the ACCORD glucose (P=0.300), lipid (P=0.660), or blood pressure interventions (P=0.469).
CONCLUSIONS:DR is associated with an increased risk of stroke, which suggests that the microvascular pathology inherent to DR has larger cerebrovascular implications. This association appears not to be mediated by serum glucose, lipid, and blood pressure interventions.
Objective
Although intravenous alteplase (IV‐tPA) has a beneficial effect on functional outcome after ischemic stroke (IS), prior studies of IV‐tPA's impact on post‐stroke mortality did not have ...sufficient representation of more severe stroke.
Methods
We determined if the interaction between the baseline National Institutes of Health (NIH) Stroke Scale (NIHSS) and IV‐tPA modified the risk of mortality after IS in two cohorts: (1) National Inpatient Sample 2016–2020, and (2) a harmonized cohort of IS patients from the NINDS IV‐tPA, ALIAS part 2, SHINE, FAST‐MAG, IMS‐III, POINT, and DEFUSE 3 trials. We fit logistic regression models to the outcome of in‐hospital mortality (National Inpatient Sample NIS cohort) or mortality within 90 days (harmonized cohort), adjusted for baseline variables.
Results
We included 198,668 patients in the NIS cohort, of which 14.0% received IV‐tPA and 3.4% died in hospital. We included 7,138 patients in the harmonized cohort, of which 33.2% received IV‐tPA and 9.4% died by 90 days. Mortality in the NIS cohort was associated with older age, female sex, non‐Hispanic white race, atrial fibrillation, and higher NIHSS. In the harmonized cohort, mortality was associated with older age, diabetes, atrial fibrillation, and higher NIHSS. In both cohorts, the interaction between NIHSS and IV‐tPA was significant. In the NIS cohort, the separation became significant at NIHSS 15 and in the harmonized cohort at NIHSS 23, at which point, IV‐tPA began to have a significant benefit for both in‐hospital and 90‐day mortality, respectively.
Interpretation
IV‐tPA is associated with a reduction in both in‐hospital and 90‐day mortality for patients with more severe IS. ANN NEUROL 2023;93:1106–1116
Treatment of uncontrolled arterial hypertension reduces the risk of cerebral small vessel disease (CSVD) progression, although it is unclear whether this reduction occurs due to blood pressure ...control or class-specific pleiotropic effects, such as improved beat-to-beat arterial pressure variability with calcium channel blockers. The goal of this study was to investigate the influence of antihypertensive medication class, particularly with calcium channel blocker, on accumulation of white matter hyperintensities (WMH), a radiographic marker of CSVD, within a cohort with well-controlled hypertension.
We completed an observational cohort analysis of the SPRINT-MIND trial (Systolic Blood Pressure Trial Memory and Cognition in Decreased Hypertension), a large randomized controlled trial of participants who completed a baseline and 4-year follow-up brain magnetic resonance image with volumetric WMH data. Antihypertensive medication data were recorded at follow-up visits between the magnetic resonance images. A percentage of follow-up time participants were prescribed each of the 11 classes of antihypertensive was then derived. Progression of CSVD was calculated as the difference in WMH volume between 2 scans and, to address skew, dichotomized into a top tertile of the distribution compared with the remaining.
Among 448 individuals, vascular risk profiles were similar across WMH progression subgroups except age (70.1±7.9 versus 65.7±7.3 years;
<0.001) and systolic blood pressure (128.3±11.0 versus 126.2±9.4 mm Hg;
=0.039). Seventy-two (48.3%) of the top tertile cohort and 177 (59.2%) of the remaining cohort were in the intensive blood pressure arm. Those within the top tertile of progression had a mean WMH progression of 4.7±4.3 mL compared with 0.13±1.0 mL (
<0.001). Use of angiotensin-converting enzyme inhibitors (odds ratio, 0.36 95% CI, 0.16-0.79;
=0.011) and dihydropyridine calcium channel blockers (odds ratio, 0.39 95% CI, 0.19-0.80;
=0.011) was associated with less WMH progression, although dihydropyridine calcium channel blockers lost significance when WMH was treated as a continuous variable.
Among participants of SPRINT-MIND trial, angiotensin-converting enzyme inhibitor was most consistently associated with less WMH progression independent of blood pressure control and age.
Background
Extremes of both high and low systolic blood pressure (SBP) after mechanical thrombectomy (MT) in large artery occlusion stroke are known predictors of unfavorable outcome. However, the ...effect of SBP change (∆SBP) during the first 24 h on thrombectomy outcomes remains unclear. We aimed to investigate the association between ∆SBP at different time intervals and thrombectomy outcomes.
Methods
We analyzed MT‐treated patients registered in the SITS International Stroke Thrombectomy Registry from January 1, 2014 to September 3, 2019. Primary outcome was 3‐month unfavorable outcome (modified Rankin scale scores 3–6). We defined ∆SBP as the mean SBP of a given time interval after MT (0–2, 2–4, 4–12, 12–24 h) minus admission SBP. Multivariable mixed logistic regression models were used to adjust for known confounders and center as random effect. Subgroup analyses were included to contrast specific subpopulations. Restricted cubic splines were used to model the associations.
Results
The study population consisted of 5835 patients (mean age 70 years, 51% male, median NIHSS 16). Mean ∆SBP was −12.3, −15.7, −17.2, and −16.9 mmHg for the time intervals 0–2, 2–4, 4–12 h, and 12–24 h, respectively. Higher ∆SBP was associated with unfavorable outcome at 0–2 h (odds ratio 1.065, 95% confidence interval 1.014–1.118), 2–4 h (1.140, 1.081–1.203), 4–12 h (1.145, 1.087–1.203), and 12–24 h (1.145, 1.089–1.203), for every increase of 10 mmHg. Restricted cubic spline models suggested that increasing ∆SBP was associated with unfavorable outcome, with higher values showing increased risk of unfavorable outcome.
Conclusion
SBP increase after thrombectomy in large artery occlusion stroke is associated with poor functional outcome.
In acute ischemic stroke patients treated with mechanical thrombectomy, systolic blood pressure (SBP) change from baseline is associated with poor functional outcome. The association between SBP change and poor outcome was mostly linear; however, increasingly worse outcomes were observed for increasing SBP.
Brain imaging is essential to the clinical care of patients with stroke, a leading cause of disability and death worldwide. Whereas advanced neuroimaging techniques offer opportunities for aiding ...acute stroke management, several factors, including time delays, inter‐clinician variability, and lack of systemic conglomeration of clinical information, hinder their maximal utility. Recent advances in deep machine learning (DL) offer new strategies for harnessing computational medical image analysis to inform decision making in acute stroke. We examine the current state of the field for DL models in stroke triage. First, we provide a brief, clinical practice‐focused primer on DL. Next, we examine real‐world examples of DL applications in pixel‐wise labeling, volumetric lesion segmentation, stroke detection, and prediction of tissue fate postintervention. We evaluate recent deployments of deep neural networks and their ability to automatically select relevant clinical features for acute decision making, reduce inter‐rater variability, and boost reliability in rapid neuroimaging assessments, and integrate neuroimaging with electronic medical record (EMR) data in order to support clinicians in routine and triage stroke management. Ultimately, we aim to provide a framework for critically evaluating existing automated approaches, thus equipping clinicians with the ability to understand and potentially apply DL approaches in order to address challenges in clinical practice. ANN NEUROL 2022;92:574–587
Objective
Anticoagulation therapy is commonly interrupted in patients with atrial fibrillation (AF) for elective procedures. However, the risk factors of acute ischemic stroke (AIS) during the ...periprocedural period remain uncertain. We performed a nationwide analysis to evaluate AIS risk factors in patients with AF undergoing elective surgical procedures.
Methods
Using the Nationwide Readmission Database, we included electively admitted adult patients with AF and procedural Diagnosis‐Related Group codes from 2016 to 2019. Diagnoses were identified based on International Classification of Disease, 9th revision‐Clinical Modification (ICD‐10 CM) codes. We constructed a logistic regression model to identify risk factors and developed a new scoring system incorporating CHA2DS2VASc to estimate periprocedural AIS risk.
Results
Of the 1,045,293 patients with AF admitted for an elective procedure, the mean age was 71.5 years, 39.2% were women, and 0.70% had a perioperative AIS during the index admission or within 30 days of discharge. Active cancer (adjusted OR aOR = 1.58, 95% confidence interval CI = 1.42–1.76), renal failure (aOR = 1.14, 95% CI = 1.04–1.24), neurological surgery (aOR = 4.51, 95% CI = 3.84–5.30), cardiovascular surgery (aOR = 2.74, 95% CI = 2.52–2.97), and higher CHA2DS2VASc scores (aOR 1.25 per point, 95% CI 1.22–1.29) were significant risk factors for periprocedural AIS. The new scoring system (area under the receiver operating characteristic curve AUC = 0.68, 95% CI = 0.67 to 0.79) incorporating surgical type and cancer outperformed CHA2DS2VASc (AUC = 0.60, 95% CI = 0.60 to 0.61).
Interpretation
In patients with AF, periprocedural AIS risk increases with the CHA2DS2VASc score, active cancer, and cardiovascular or neurological surgeries. Studies are needed to devise better strategies to mitigate perioperative AIS risk in these patients. ANN NEUROL 2023;94:321–329
Background and purpose
The genetics of late seizure or epilepsy secondary to traumatic brain injury (TBI) or stroke are poorly understood. We undertook a systematic review to test the association of ...single‐nucleotide polymorphisms (SNPs) with the risk of post‐traumatic epilepsy (PTE) and post‐stroke epilepsy (PSE).
Methods
We followed methods from our prespecified protocol on PROSPERO to identify indexed articles for this systematic review. We collated the association statistics from the included articles to assess the association of SNPs with the risk of epilepsy amongst TBI or stroke patients. We assessed study quality using the Q‐Genie tool. We report odds ratios (OR) and hazard ratios with 95% confidence intervals (CIs).
Results
The literature search yielded 420 articles. We included 16 studies in our systematic review, of which seven were of poor quality. We examined published data on 127 SNPs from 32 genes identified in PTE and PSE patients. Eleven SNPs were associated with a significantly increased risk of PTE. Three SNPs, TRMP6 rs2274924, ALDH2 rs671, and CD40 ‐1C/T, were significantly associated with an increased risk of PSE, while two, AT1R rs12721273 and rs55707609, were significantly associated with reduced risk. The meta‐analysis for the association of the APOE ɛ4 with PTE was nonsignificant (OR 1.8, CI 0.6–5.6).
Conclusions
The current evidence on the association of genetic polymorphisms in epilepsy secondary to TBI or stroke is of low quality and lacks validation. A collaborative effort to pool genetic data linked to epileptogenesis in stroke and TBI patients is warranted.
Background Stenosis has historically been the major factor used to determine carotid stroke sources. Recent evidence suggests that specific plaque features detected on imaging may be more highly ...associated with ischemic stroke than stenosis. We sought to determine computed tomography angiography (CTA) imaging features of carotid plaque that optimally discriminate ipsilateral stroke sources. Methods and Results In this institutional review board-approved retrospective cross-sectional study, 494 ipsilateral carotid CTA-brain magnetic resonance imaging pairs were available for analysis after excluding patients with alternative stroke sources. Carotid CTA and clinical markers were recorded, a multivariable Poisson regression model was fitted, and backward elimination was performed with a 2-sided threshold of
<0.10. Discriminatory value was determined using receiver operating characteristic analysis, area under the curve, and bootstrap validation. The final CTA carotid-source stroke prediction model included intraluminal thrombus (prevalence ratio, 2.8
<0.001; 95% CI, 1.6-4.9), maximum soft plaque thickness (prevalence ratio, 1.2
<0.001; 95% CI, 1.1-1.4), and the rim sign (prevalence ratio, 2.0
=0.007; 95% CI, 1.2-3.3). The final discriminatory value (area under the curve=78.3%) was higher than intraluminal thrombus (56.4%,
<0.001), maximum soft plaque thickness (76.4%,
=0.007), or rim sign alone (69.9%,
=0.001). Furthermore, NASCET (North American Symptomatic Carotid Endarterectomy Trial) stenosis categories (cutoffs of 50% and 70%) had lower stroke discrimination (area under the curve=67.4%,
<0.001). Conclusions Optimal discrimination of ipsilateral carotid sources of stroke requires information on intraluminal thrombus, maximum soft plaque thickness, and the rim sign. These results argue against the sole use of carotid stenosis to determine stroke sources on CTA, and instead suggest these alternative markers may better diagnose vulnerable carotid plaque and guide treatment decisions.
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