Background and purpose
The aim of this study was to describe the clinical and epidemiological characteristics of acute ischaemic stroke (AIS) in patients with atrial fibrillation (AF) previously ...treated with oral anticoagulants (OACs) according to the type of OAC prescribed. Also, to analyze the outcomes of the patients and the therapeutic approach adopted by the neurologist in the acute phase and for secondary prevention.
Methods
We performed a multicenter, observational study based on prospective registries. We included patients with AF treated with OACs admitted for AIS over a 1‐year period. Detailed clinical data and functional outcome at 3 months (modified Rankin Scale score) were collected. Patients were divided into two groups according to their pre‐AIS anticoagulant therapy: vitamin K antagonists (AIS‐VKA) and direct‐acting OACs (AIS‐DOAC).
Results
We recruited 1240 patients (80.4% AIS‐VKA and 19.6% AIS‐DOAC). In the AIS‐DOAC group, transient ischaemic attack was more frequent (18.1% vs. 10.8%; P = 0.001), symptomatic hemorrhagic transformation was less frequent (1.6% vs. 4.6%; P = 0.035) and hospital stay was shorter (median 6 vs. 7 days; P = 0.03). Intravenous thrombolysis was more commonly used in AIS‐VKA (9.2% vs. 1.6%; P < 0.001). There were no differences between the groups with respect to mechanical thrombectomy, mortality and modified Rankin Scale score at 3 months. At 3 months, 54% of patients required a DOAC as antithrombotic treatment for secondary prevention.
Conclusions
Patients with AF treated with DOACs who experienced AIS more frequently had transient symptoms (transient ischaemic attack), less symptomatic hemorrhagic transformation and a shorter mean stay than those treated with VKAs. Most patients who had been previously anticoagulated with AIS received long‐term treatment with DOACs.
Purpose
The ultrasonographic and hemodynamic features of patients with carotid near-occlusion (CNO) are still not well known. Our aim was to describe the ultrasonographic and hemodynamic ...characteristics of a cohort of patients with CNO.
Methods
A prospective, observational, nationwide, and multicenter study was conducted from January/2010 to May/2016. Patients with digital subtraction angiography (DSA)–confirmed CNO were included. We collected information on clinical and demographic characteristics, carotid and transcranial ultrasonography and DSA findings, presence of full-collapse, collateral circulation, and cerebrovascular reactivity (CVR).
Results
One hundred thirty-five patients were analyzed. Ultrasonographic and DSA diagnosis of CNO were concordant in only 44%. This disagreement was related to the presence/absence of full-collapse: 45% of patients with CNO with full-collapse were classified as a complete carotid occlusion, and 40% with a CNO without full-collapse were interpreted as severe stenosis (
p
< 0.001). Mean velocities (mV) and pulsatility indexes (PIs) were significantly lower in the ipsilateral middle cerebral artery compared with the contralateral (43 cm/s vs 58 cm/s,
p
< 0.001; 0.80 vs 1.00,
p
< 0.001). Collateral circulation was identified in 92% of patients, with the anterior communicating artery (73%) being the most frequent. CVR was decreased or exhausted in 66% of cases and was more frequent in patients with a poor or absent collateral network compared with patients with ≥ 2 collateral arteries (82% vs 56%,
p
= 0.051).
Conclusion
The accuracy of carotid ultrasonography in the diagnosis of CNO seems to be limited, with significant discrepancies with DSA. Decreased ipsilateral mV, PI, and CVR suggest a hemodynamic compromise in patients with CNO.
Several clinical scales have been developed for predicting stroke recurrence. These clinical scores could be extremely useful to guide triage decisions. Our goal was to compare the very early ...predictive accuracy of the most relevant clinical scores age, blood pressure, clinical features and duration of symptoms (ABCD) score, ABCD and diabetes (ABCD2) score, ABCD and brain infarction on imaging score, ABCD2 and brain infarction on imaging score, ABCD and prior TIA within 1 week of the index event (ABCD3) score, California Risk Score, Essen Stroke Risk Score and Stroke Prognosis Instrument II in consecutive transient ischemic attack (TIA) patients.
Between April 2008 and December 2009, we included 1,255 consecutive TIA patients from 30 Spanish stroke centers (PROMAPA study). A neurologist treated all patients within the first 48 h after symptom onset. The duration and typology of clinical symptoms, vascular risk factors and etiological work-ups were prospectively recorded in a case report form in order to calculate established prognostic scores. We determined the early short-term risk of stroke (at 7 and 90 days). To evaluate the performance of each model, we calculated the area under the receiver operating characteristic curve. Cox proportional hazards multivariate analyses determining independent predictors of stroke recurrence using the different components of all clinical scores were calculated.
We calculated clinical scales for 1,137 patients (90.6%). Seven-day and 90-day stroke risks were 2.6 and 3.8%, respectively. Large-artery atherosclerosis (LAA) was observed in 190 patients (16.7%). We could confirm the predictive value of the ABCD3 score for stroke recurrence at the 7-day follow-up 0.66, 95% confidence interval (CI) 0.54-0.77 and 90-day follow-up (0.61, 95% CI 0.52-0.70), which improved when we added vascular imaging information and derived ABCD3V scores by assigning 2 points for at least 50% symptomatic stenosis on carotid or intracranial imaging (0.69, 95% CI 0.57-0.81, and 0.63, 95% CI 0.51-0.69, respectively). When we evaluated each component of all clinical scores using Cox regression analyses, we observed that prior TIA and LAA were independent predictors of stroke recurrence at the 7-day follow-up hazard ratio (HR) 3.97, 95% CI 1.91-8.26, p < 0.001, and HR 3.11, 95% CI 1.47-6.58, p = 0.003, respectively and 90-day follow-up (HR 2.35, 95% CI 1.28-4.31, p = 0.006, and HR 2.20, 95% CI 1.15-4.21, p = 0.018, respectively).
All published scores that do not take into account vascular imaging or prior TIA when identifying stroke risk after TIA failed to predict risk when applied by neurologists. Clinical scores were not able to replace extensive emergent diagnostic evaluations such as vascular imaging, and they should take into account unstable patients with recent prior transient episodes.
We present an update of the Spanish Society of Neurology’s recommendations for prevention of both primary and secondary stroke in patients with dyslipidaemia.
We performed a systematic review to ...evaluate the main aspects of the management of dyslipidaemias in primary and secondary stroke prevention and establish a series of recommendations.
In primary prevention, the patient’s vascular risk should be determined in order to define target values for low-density lipoprotein cholesterol. In secondary prevention after an atherothrombotic stroke, a target value <55 mg/dL is recommended; in non-atherothombotic ischaemic strokes, given the unclear relationship with dyslipidaemia, target value should be established according to the vascular risk group of each patient. In both primary and secondary prevention, statins are the drugs of first choice, and ezetimibe and/or PCSK9 inhibitors may be added in patients not achieving the target value.
Actualizar las recomendaciones de la Sociedad Española de Neurología para la prevención del ictus, tanto primaria como secundaria en pacientes con dislipidemia.
Se ha realizado una revisión sistemática en Pubmed evaluando los principales aspectos relacionados con el manejo de las dislipidemias en la prevención primaria y secundaria del ictus, elaborándose una serie de recomendaciones relacionadas con los mismos.
En prevención primaria se recomienda determinar el riesgo vascular del paciente con el fin de definir los objetivos de LDLc. En prevención secundaria tras un ictus de origen aterotrombótico se recomienda un objetivo de LDLc < 55 mg/dl, mientras que en ictus isquémicos de origen no aterotrombótico dado que su relación con dislipidemias es incierta se establecerán los objetivos en base al grupo de riesgo vascular de cada paciente. Tanto en prevención primaria como secundaria las estatinas son los fármacos de primera elección, pudiendo asociarse ezetimiba y/o inhibidores de PCSK9 en aquellos casos que no alcancen los objetivos terapéuticos.
Recent analyses emphasise that The Benchmark Stroke Door-to-Needle Time (DNT) should be 30min. This study aimed to determine if a new in-hospital IVT protocol is effective in reducing door-to-needle ...time and correcting previously identified factors associated with delays.
In 2014, we gradually introduced a series of measures aimed to reduce door-to-needle time for patients receiving IVT, and compared it before (2009-2012) and after (2014-2017) the new protocol was introduced.
The sample included 239 patients before and 222 after the introduction of the protocol. Median overall door-to-needle time was 27min after the protocol was fully implemented (a 48% reduction on previous door-to-needle time 52min, P<.001). Median door-to-needle time was lower when pre-hospital code stroke was activated (22min). We observed a 26-min reduction in the median time from onset to treatment (P<.001). After the protocol was implemented, the “3-hour-effect” did not affect door-to-needle time (P=.98). Computed tomography angiography studies performed before IVT were associated with increased door-to-needle time (P<.001); however, the test was performed after IVT was started in most cases.
Hospital reorganisation and multidisciplinary collaboration brought median door-to-needle time below 30min and corrected previously identified delay factors. Furthermore, overall time from onset to treatment was also reduced and more stroke patients were treated within 90min of symptom onset.
El objetivo del tiempo puerta-aguja en el ictus isquémico agudo tratado con trombólisis intravenosa (TIV) tiende a situarse actualmente en los 30min. Determinamos si un nuevo protocolo de actuación intrahospitalario es eficaz para reducir el intervalo puerta-aguja y corregir los factores de demora previamente identificados.
En 2014 se implantaron gradualmente unas medidas diseñadas para acortar los tiempos de actuación intrahospitalarios en los pacientes tratados con TIV. Se compararon los tiempos de actuación antes (2009-2012) y después (febrero 2014-abril 2017) de la introducción del nuevo protocolo.
Se incluyeron 239 pacientes antes y 222 después. Cuando todas las medidas fueron introducidas, la mediana global de tiempo puerta-aguja fue de 27min (previa 52min, 48% menos, p<0,001) y de 22min cuando se activó el código ictus extrahospitalario. El tiempo global al tratamiento (inicio-aguja) se redujo en 26min de mediana (p<0,001). En el período postintervención ya no se objetivó el «efecto de fin de ventana» (p=0,98). Aunque la angio-TC antes de la TIV continuó retrasando los tiempos de actuación (p<0,001), tras el nuevo protocolo, esta prueba se realizó después del inicio del tratamiento en la mayoría de los casos.
La reorganización intrahospitalaria y la colaboración multidisciplinar han situado la mediana de tiempo puerta-aguja por debajo de los 30min y han corregido los factores de demora identificados previamente. Además, se ha reducido el tiempo global al tratamiento y una mayor proporción de pacientes son tratados en los primeros 90min desde el inicio de los síntomas.
To update the recommendations of the Spanish Society of Neurology on primary and secondary stroke prevention in patients with arterial hypertension.
We proposed several questions to identify ...practical issues for the management of blood pressure (BP) in stroke prevention, analysing the objectives of blood pressure control, which drugs are most appropriate in primary prevention, when antihypertensive treatment should be started after a stroke, what levels we should aim to achieve, and which drugs are most appropriate in secondary stroke prevention. We conducted a systematic review of the PubMed database and analysed the main clinical trials to address these questions and establish a series of recommendations.
In primary stroke prevention, antihypertensive treatment should be started in patients with BP levels > 140/90 mmHg, with a target BP of < 130/80 mmHg. In secondary stroke prevention, we recommend starting antihypertensive treatment after the acute phase (first 24 hours), with a target BP of < 130/80 mmHg. The use of angiotensin-II receptor antagonists or diuretics alone or in combination with angiotensin-converting enzyme inhibitors is preferable.
Actualizar las recomendaciones de la Sociedad Española de Neurología para la prevención de ictus, tanto primaria como secundaria, en pacientes con hipertensión arterial.
Se han planteado diferentes preguntas para identificar cuestiones prácticas para el manejo de la presión arterial (PA) en prevención de ictus, analizando cuál debe ser el objetivo de control de la presión arterial y cuáles son los fármacos más adecuados en prevención primaria, cuándo iniciar el tratamiento antihipertensivo después de un ictus, cuáles son las cifras que debemos alcanzar y qué fármacos son los más adecuados en prevención secundaria de ictus. Se ha realizado una revisión sistemática en Pubmed analizando los principales ensayos clínicos para dar respuesta a estas preguntas y se han elaborado unas recomendaciones.
En prevención primaria se recomienda iniciar tratamiento antihipertensivo con cifras de PA > 140/90 mmHg, con un objetivo de control de PA < 130/80 mmHg. En prevención secundaria de ictus se recomienda iniciar tratamiento antihipertensivo pasada la fase aguda (primeras 24 h) con un objetivo de control de PA < 130/80 mmHg, siendo preferible el empleo de ARA-II o diuréticos solos o en combinación con IECA.
To update the recommendations of the Spanish Society of Neurology regarding lifestyle interventions for stroke prevention.
We reviewed the most recent studies related to lifestyle and stroke risk, ...including randomised clinical trials, population studies, and meta-analyses. The risk of stroke associated with such lifestyle habits as smoking, alcohol consumption, stress, diet, obesity, and sedentary lifestyles was analysed, and the potential benefits for stroke prevention of modifying these habits were reviewed. We also reviewed stroke risk associated with exposure to air pollution. Based on the results obtained, we drafted recommendations addressing each of the lifestyle habits analysed.
Lifestyle modification constitutes a cornerstone in the primary and secondary prevention of stroke. Abstinence or cessation of smoking, cessation of excessive alcohol consumption, avoidance of exposure to chronic stress, avoidance of overweight or obesity, a Mediterranean diet supplemented with olive oil and nuts, and regular exercise are essential measures in reducing the risk of stroke. We also recommend implementing policies to reduce air pollution.
Actualizar las recomendaciones de la Sociedad Española de Neurología relativas a la actuación sobre los hábitos de vida para la prevención del ictus.
Se ha realizado una revisión de los estudios más recientes relacionados con los hábitos de vida y el riesgo de ictus, incluyendo ensayos clínicos aleatorizados, estudios poblacionales y meta-análisis. Se ha analizado el riesgo de ictus asociado con determinados hábitos de vida como el tabaquismo, el consumo de alcohol, el estrés, la dieta, la obesidad y el sedentarismo, y se ha revisado el potencial beneficio que la modificación de esos hábitos de vida puede aportar en la prevención del ictus. Asimismo, se ha revisado el riesgo de ictus asociado a la exposición a la contaminación atmosférica. A partir de los resultados obtenidos se han redactado unas recomendaciones sobre cada uno de los hábitos de vida analizados.
La actuación sobre los hábitos de vida constituye una piedra angular en la prevención primaria y secundaria del ictus. La abstinencia o cese del hábito tabáquico, el cese del consumo excesivo de alcohol, evitar la exposición a estrés crónico, evitar el sobrepeso o la obesidad, seguir una dieta mediterránea suplementada con aceite de oliva y frutos secos, y la práctica regular de actividad física son medidas fundamentales para reducir el riesgo de sufrir un ictus. Además, se aconseja desarrollar políticas encaminadas a disminuir la contaminación atmosférica.
Resumen Objetivo Identificar los factores que influyen en el tiempo puerta-aguja (tiempo P-A) en la administración de trombólisis intravenosa (TIV) en un hospital terciario para diseñar futuras ...estrategias que acorten los tiempos. Métodos Estudio retrospectivo de pacientes tratados con TIV entre 2009 y 2012. Analizamos la relación entre el tiempo P-A y los siguientes factores: edad, sexo, antecedentes personales, tiempo inicio-puerta, activación de código ictus extrahospitalario (CIE), glucemia y presión arterial basal, NIHSS basal, realización de angio-TC o estudio neurosonológico previo, hora de llegada al hospital, día de la semana y año del ictus. Resultados Hubo un total de 239 pacientes tratados. Tiempos de actuación en min (mediana rango intercuartílico): tiempo inicio-puerta 84 (60-120); tiempo puerta-TC 17 (13-24,75) tiempo TC-aguja 34 (26-47); tiempo puerta-aguja 52 (43-70); tiempo inicio-aguja 145 (120-180). El tiempo P-A fue significativamente menor con la activación del CIE: 51 vs. 72 (p = 0,008), y mayor con la realización de angio-TC: 59 vs. 48,5 (p = 0,004) y con tiempo inicio-puerta < 90 min: 58 vs. 48 (p = 0,003). En el análisis de regresión lineal múltiple 2 factores redujeron significativamente el tiempo P-A: la activación de CIE (reducción = 26,3%; p < 0,001) y el tiempo inicio-puerta (por cada 30 min de tiempo inicio-puerta, el tiempo P-A se acortó 4,7 min; p = 0,02). Por el contrario realizar una angio-TC aumentó un 13,4% el tiempo P-A (p = 0,03). Los demás factores no influyeron significativamente en el tiempo P-A. Conclusiones La realización de angio-TC y el «efecto de las 3 h» son 2 factores que retrasan el inicio de la TIV en nuestro hospital. Por el contrario el CIE reduce claramente los tiempos P-A. Los resultados de este estudio nos han permitido identificar qué factores retrasan nuestra actuación y servirán en un futuro para intentar disminuir los tiempos P-A en nuestro hospital.
This paper addresses the problem of understanding the relationship between fluid flow and heat transfer in industrial quenching systems. It also presents an efficient analysis to design or optimize ...long standing quenching tanks to increase productivity. The study case is automotive leaf springs quenched in an oil-tank agitated with submerged jets. This analysis combined an efficient numerical prediction of the detailed isothermal flow field in the whole tank with the thermal characterization of steel probes in plant and laboratory during quenching. These measurements were used to determine the heat flow by solving the inverse heat conduction problem. Differences between laboratory and plant heat flux results were attributed to the difference in surface area size between samples. A proposed correlation between isothermal wall shear stress and heat flux at the surface of the steel component, based on the Reynolds-Colburn analogy, provided the connection between thermal characterization and computed isothermal fluid flow. The present approach allowed the identification of the potential benefits of changes in the tank design and the evaluation of operating conditions while using a much shorter computing time and storage memory than full-domain fluid flow calculations.
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