The epidemiology of acute renal dysfunction after stroke is routinely overlooked following stroke events. Our aim in this meta-analysis is to report the prevalence of acute kidney injury (AKI) ...following acute stroke and its impact on mortality.
A systematic literature search was performed on PubMed, EMBASE and Google Scholar for observational studies examining the prevalence and mortality risk of stroke patients with AKI as a complication. The pooled prevalence rates and odds ratios for mortality risk were calculated using subgroup analyses between the stroke subtypes: acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH).
A total of 12 studies (4,532,181 AIS and 615,636 ICH) were included. The pooled prevalence rate of AKI after all stroke types was 11.6% (95% CI 10.6-12.7). Subgroup analyses revealed that the pooled prevalence rate of AKI after AIS was greater but not statistically significantly different than ICH (19.0%; 95% CI 8.2-29.7 vs. 12.9%; 95% CI 10.3-15.5, p = 0.5). AKI was found to be a significant risk factor of mortality in AIS (adjusted OR aOR 2.23; 95% CI 1.28-3.89; I2 = 98.8%), whereas this relationship did not reach statistical significance in ICH (aOR 1.20; 95% CI 0.68-2.12; I2 = 74.2%).
This meta-analysis provides evidence that AKI is a common complication following both AIS and ICH and it is associated with increased mortality following AIS but not ICH. This highlights the need for early assessment of renal function in the acute phase of AIS, in particular, and avoidance of factors than may induce AKI in vulnerable patients.
A nationwide database study conducted entirely in the modern era of stenting strongly supports this view.2 Despite there being no randomised trials of transcarotid artery stenting, the observational ...data to date suggest that it is as safe and efficacious as carotid endarterectomy when offered to highly selected (ie, based on very specific inclusion criteria) patients.4 The argument that CMS's expansion might imperil recruitment to the CREST-2 trial, or a CREST-3 if ever undertaken, seems overstated. ...its results, which are years away, will be useful in planning additional studies and guiding regulatory agency revisions when wedded to observational outcomes and economic data afforded by this expanded coverage. The lack of confirmation of stenosis has been driven at least in part by the restrictive CMS standards for revascularisation.5 Furthermore, once a decision was made to intervene, the CMS guidelines limited the surgeon's flexibility to decide the best intervention, which restricted a personalised discussion of risk and benefit. While we emphatically agree with Abbott and colleagues that every effort should be made to protect against patient exploitation and over-treatment by inexperienced and unmonitored clinicians, the easing of CMS restrictions could improve rather than diminish experience and monitoring.
The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH).
A formal literature search of MEDLINE ...(November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years.
Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications.
aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.
Abstract The recent emergence of mobile health – the use of mobile telecommunication and wireless devices to improve health outcomes, services, and research – has inspired a patient-centric approach ...to monitor health metrics. Sensors embedded in wearable devices are utilized to acquire greater self-knowledge by tracking basic parameters such as blood pressure, heart rate, and body temperature as well as data related to exercise, diet, and psychological state. To that end, recent studies on utilizing wireless fitness activity trackers to monitor and promote functional recovery in patients suggest that collecting up-to-date performance data could help patients regain functional independence and help hospitals determine the appropriate length of stay for a patient. This manuscript examines existing functional assessment scales, discusses the use of activity tracking sensors in evaluating functional independence, and explores the growing application of wireless technology in measuring and promoting functional recovery.
PURPOSE—The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms.
METHODS—Writing group ...members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
RESULTS—Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment.
Background Hyponatremia is a common metabolic disturbance after aneurysmal subarachnoid hemorrhage (SAH), and it may worsen outcomes. This review aims to characterize the effect of hyponatremia on ...morbidity and mortality after SAH. Objectives We sought to determine the prevalence of hyponatremia after SAH, including in subgroups, as well as its effect on mortality and certain outcome measures, including degree of disability and duration of hospitalization. Methods A search of terms “hyponatremia” and “subarachnoid hemorrhage” was performed on PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE. Studies were included if they reported prevalence of hyponatremia and if they discussed outcomes such as mortality, duration of stay, functional outcomes (e.g., Glasgow Outcomes Scale), or incidence of complications in patients with aneurysmal SAH. Two independent researchers assessed the titles and abstracts and reviewed articles for inclusion. Results Thirteen studies met inclusion criteria. The prevalence of at least mild hyponatremia was 859 of 2387 (36%) of patients. Hyponatremia was associated with vasospasm and duration of hospitalization, but it did not influence mortality. Conclusion Hyponatremia is common after SAH, and there is evidence that it is associated with certain poorer outcomes. Larger, prospective studies are needed to assess these findings and provide further evidence.
Current Status of Endovascular Stroke Treatment MEYERS, Philip M; CHRISTIAN SCHUMACHER, H; SANDER CONNOLLY, E ...
Circulation (New York, N.Y.),
06/2011, Letnik:
123, Številka:
22
Journal Article
Recenzirano
Odprti dostop
The management of acute ischemic stroke is rapidly developing.Although acute ischemic stroke is a major cause of adult disability and death, the number of patients requiring emergency endovascular ...intervention remains unknown, but is a fraction of the overall stroke population. Public health initiatives endeavor to raise public awareness about acute stroke to improve triage for emergency treatment, and the medical community is working to develop stroke services at community and academic medical centers throughout the United States. There is an Accreditation Council for Graduate Medical Education–approved pathway for training in endovascular surgical neuroradiology, the specialty designed to train physicians specifically to treat cerebrovascular diseases. Primary and comprehensive stroke center designations have been defined, yet questions remain about the best delivery model. Telemedicine is available to help community medical centers cope with the complexity of stroke triage and treatment. Should comprehensive care be provided at every community center, or should patients with complex medical needs be triaged to major stroke centers with high-level surgical,intensive care, and endovascular capabilities? Although the answers to these and other questions about stroke care delivery remain unanswered owing to the paucity of empirical data, we are convinced that stroke care regionalization is crucial for delivery of high-quality comprehensive ischemic stroke treatment. A stroke team available 24 hours per day, 7 days per week requires specialty skills in stroke neurology, endovascular surgical neuroradiology, neurosurgery, neurointensive care, anesthesiology, nursing, and technical support for optimal success. Several physician groups with divergent training backgrounds (i.e., interventional neuroradiology, neurosurgery,neurology, peripheral interventional radiology, and cardiology) lay claim to the treatment of stroke patients,particularly the endovascular or interventional methods. Few would challenge neurologists over the responsibility for emergency evaluation and triage of stroke victims for intra intravenous fibrinolysis, even though emergency physicians are most commonly the first to evaluate these patients. There are many unanswered questions about the role of imaging in defining best treatment. Perfusion imaging with CT or MRI appears to have relevance even though its role remains undefined and is the subject of ongoing research. Meanwhile, investigators are exploring new, and perhaps more specific,imaging methods with cerebral metabolic rate of oxygen and cellular acid-base imbalance. There are currently 6 ongoing trials of stroke intervention, many with proprietary technologies and private funding, competing for the same patient population as multicenter trials funded by the NIH. At the same time, much of the interventional stroke treatment currently occurs outside of trials in the community and academic settings without the collection of much-needed data. Market forces will certainly shape future stroke therapy, but it is unclear whether the current combination of private and public funding for these endeavors is the best method of development.
Carotid-cavernous fistulas (CCFs) are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. The characteristic clinical features seen in patients with CCFs are the ...sequelae of hemodynamic dysfunction within the cavernous sinus. Once routinely treated with open surgical procedures, including carotid ligation or trapping and cavernous sinus exploration, endovascular therapy is now the treatment modality of choice in many cases. The authors provide a review of CCFs, detailing the current classification and clinical management of these lesions. Therapeutic options including conservative management, open surgery, endovascular intervention, and radiosurgical therapy are presented. The complications and treatment results as reported in the contemporary literature are also reviewed.
This systematic review, meta-analysis, and novel time course analysis examines microvascular failure in the treatment of acute ischemic stroke (AIS) patients undergoing endovascular therapy (EVT) ...and/or thrombolytic administration for stroke management. A systematic review and meta-analysis following PRIMSA-2020 guidelines was conducted along with a novel curve-of-best fit analysis to elucidate the time-course of microvascular failure. Scopus and PubMed were searched using relevant keywords to identify studies that examine recanalization and reperfusion assessment of AIS patients following large vessel occlusion. Meta-analysis was conducted using a random-effects model. Curve-of-best-fit analysis of microvascular failure rate was performed with a negative exponential model. Twenty-seven studies with 1151 patients were included. Fourteen studies evaluated patients within a standard stroke onset-to-treatment time window (≤6 hours after last known normal) and thirteen studies had an extended time window (>6 hours). Our analysis yields a 22% event rate of microvascular failure following successful recanalization (95% CI: 16–30%). A negative exponential curve modeled a microvascular failure rate asymptote of 28.5% for standard time window studies, with no convergence of the model for extended time window studies. Progressive microvascular failure is a phenomenon that is increasingly identified in clinical studies of AIS patients undergoing revascularization treatment.
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