BACKGROUND AND PURPOSE—We determined the effect of sex on outcome after endovascular stroke thrombectomy in acute ischemic stroke, including lifelong disability outcomes.
METHODS—We analyzed patients ...treated with the Solitaire stent retriever in the combined SWIFT (Solitaire FR With the Intention for Thrombectomy), STAR (Solitaire FR Thrombectomy for Acute Revascularization), and SWIFT PRIME (Solitaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment) cohorts. Ordinal and logistic regression were used to examine known factors influencing outcome after endovascular stroke thrombectomy and study the effect of sex on the association between these factors and outcomes, including age and time to reperfusion. Years of optimal life after thrombectomy were defined as disability-adjusted life years and calculated by projecting disability through adjusted poststroke life expectancy by sex.
RESULTS—Among 389 patients treated with endovascular stroke thrombectomy, 55% were females, and median National Institutes of Health Stroke Scale was 17 (interquartile range, 8–28). There were no differences between females versus males in presenting deficit severity (National Institutes of Health Stroke Scale score, 17 versus 17, P=0.21), occlusion location (69% versus 64% M1, P=0.62), presenting infarct extent (Alberta Stroke Program Early CT Score 8 versus 8, P=0.24), rate of substantial reperfusion (Thrombolysis in Cerebral Infarction 2b/3, 87% versus 83%, P=0.37), onset to reperfusion time (294 versus 302 minutes, P=0.46). Despite older ages (69 versus 64, P<0.001) and higher rate of atrial fibrillation (45% versus 30%, P=0.002) for females compared with males, adjusted rates of functional independence at 90 days were similar (odds ratio, 1.0; 95% CI, 0.6–1.6). After adjusting for age at presentation and stroke severity, females had more years of optimal life (disability-adjusted life year) after endovascular stroke thrombectomy, 10.6 versus 8.5 years (P<0.001).
CONCLUSIONS—Despite greater age and higher rate of atrial fibrillation, females experienced comparable functional outcomes and greater years of optimal life after intervention compared with males.
What Is a Minor Stroke? FISCHER, Urs; BAUMGARTNER, Adrian; MATTLE, Heinrich P ...
Stroke (1970),
04/2010, Letnik:
41, Številka:
4
Journal Article
Recenzirano
Odprti dostop
The term "minor stroke" is often used; however a consensus definition is lacking. We explored the relationship of 6 "minor stroke" definitions and outcome and tested their validity in subgroups of ...patients.
A total of 760 consecutive patients with acute ischemic strokes were classified according to the following definitions: A, score < or = 1 on every National Institutes of Health Stroke Scale (NIHSS) item and normal consciousness; B, lacunar-like syndrome; C, motor deficits with or without sensory deficits; D, NIHSS < or = 9 excluding those with aphasia, neglect, or decreased consciousness; E, NIHSS < or = 9; and F, NIHSS < or = 3. Short-term outcome was considered favorable when patients were discharged home, and favorable medium-term outcome was defined as a modified Rankin Scale score of < or = 2 at 3 months. The following subgroup analyses were performed by definition: sex, age, anterior versus posterior and right versus left hemispheric stroke, and early (0 to 6 hours) versus late admission (6 to 24 hours) to the hospital.
Short-term and medium-term outcomes were most favorable in patients with definition A (74% and 90%, respectively) and F (71% and 90%, respectively). Patients with definition C and anterior circulation strokes were more likely to be discharged home than patients with posterior circulation strokes (P=0.021). The medium-term outcome of older patients with definition E was less favorable compared with the outcome of younger ones (P=0.001), whereas patients with definition A, D, and F did not show different outcomes in any subgroup.
Patients fulfilling definition A and F had best short-term and medium-term outcomes. They would be best suited to the definition of "minor stroke."
Mechanical thrombectomy using stent retriever devices have been advocated to increase revascularization in intracranial vessel occlusion. We present the results of a large prospective study on the ...use of the Solitaire Flow Restoration in patients with acute ischemic stroke.
Solitaire Flow Restoration Thrombectomy for Acute Revascularization was an international, multicenter, prospective, single-arm study of Solitaire Flow Restoration thrombectomy in patients with large vessel anterior circulation strokes treated within 8 hours of symptom onset. Strict criteria for site selection were applied. The primary end point was the revascularization rate (thrombolysis in cerebral infarction ≥2b) of the occluded vessel as determined by an independent core laboratory. The secondary end point was the rate of good functional outcome (defined as 90-day modified Rankin scale, 0-2).
A total of 202 patients were enrolled across 14 comprehensive stroke centers in Europe, Canada, and Australia. The median age was 72 years, 60% were female patients. The median National Institute of Health Stroke Scale was 17. Most proximal intracranial occlusion was the internal carotid artery in 18%, and the middle cerebral artery in 82%. Successful revascularization was achieved in 79.2% of patients. Device and procedure-related severe adverse events were found in 7.4%. Favorable neurological outcome was found in 57.9%. The mortality rate was 6.9%. Any intracranial hemorrhagic transformation was found in 18.8% of patients, 1.5% were symptomatic.
In this single-arm study, treatment with the Solitaire Flow Restoration device in intracranial anterior circulation occlusions results in high rates of revascularization, low risk of clinically relevant procedural complications, and good clinical outcomes in combination with low mortality at 90 days.
http://www.clinicaltrials.gov. Unique identifier: NCT01327989.
IMPORTANCE: Achieving complete reperfusion is a key determinant of good outcome in patients treated with mechanical thrombectomy (MT). However, data on treatments geared toward improving reperfusion ...after incomplete MT are sparse. OBJECTIVE: To determine whether administration of intra-arterial urokinase is safe and improves reperfusion after failed or incomplete MT. DESIGN, SETTING, AND PARTICIPANTS: This observational cohort study included a consecutive sample of patients treated with second-generation MT from January 1, 2010, through August 4, 2017. Data were collected from the prospective registry of a tertiary care stroke center. Of 1274 patients screened, 69 refused to participate, and 993 met the observational studies inclusion criteria of a large vessel occlusion in the anterior circulation. Data were analyzed from September 1, 2017, through September 20, 2019. INTERVENTION: One hundred patients received intra-arterial urokinase after failed or incomplete MT using manual microcatheter injections. MAIN OUTCOMES AND MEASURES: Primary safety outcome was the occurrence of symptomatic intracranial hemorrhage (sICH) according to the Prolyse in Acute Cerebral Thromboembolism II criteria. Secondary end points included 90-day mortality and 90-day functional independence (defined as modified Rankin Scale score of ≤2). Efficacy was evaluated angiographically, applying the Thrombolysis in Cerebral Infarction (TICI) scale. RESULTS: After exclusion of patients with posterior circulation strokes and those treated with intra-arterial thrombolytics only, 993 patients were included in the final analyses (median age, 74.6 interquartile range, 62.6-82.2 years; 505 50.9% women). Additional intra-arterial urokinase was administered in 100 patients (10.1%). The most common reason for administering intra-arterial urokinase was incomplete reperfusion (TICI<3) after MT (53 53.0%). After adjusting for baseline characteristics underlying case selection, intra-arterial urokinase was not associated with an increased risk of sICH (adjusted odds ratio aOR, 0.81; 95% CI, 0.31-2.13) or 90-day mortality (aOR, 0.78; 95% CI, 0.43-1.40). Among 53 cases of partial or near-complete reperfusion and treated with intra-arterial urokinase, 32 (60.4%) had early reperfusion improvement, and 18 of 53 (34.0%) had an improvement in TICI grade. Correspondingly, patients treated with intra-arterial urokinase had higher rates of functional independence after adjusting for the selection bias favoring a priori poor TICI grades in the intra-arterial urokinase group (aOR, 1.93; 95% CI, 1.11-3.37). CONCLUSIONS AND RELEVANCE: In selected patients, adjunctive treatment with intra-arterial urokinase during or after MT was safe and improved angiographic reperfusion. Systemic evaluation of this approach in a multicenter prospective registry or a randomized clinical trial seems warranted.
BackgroundWhether pretreatment with intravenous thrombolysis prior to mechanical thrombectomy (IVT+MTE) adds additional benefit over direct mechanical thrombectomy (dMTE) in patients with large ...vessel occlusions (LVO) is a matter of debate.MethodsThis study-level meta-analysis was presented in accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled effect sizes were calculated using the inverse variance heterogeneity model and displayed as summary Odds Ratio (sOR) and corresponding 95% confidence interval (95% CI). Sensitivity analysis was performed by distinguishing between studies including dMTE patients eligible for IVT (IVT-E) or ineligible for IVT (IVT-IN). Primary outcome measures were functional independence (modified Rankin Scale≤2) and mortality at day 90, successful reperfusion, and symptomatic intracerebral hemorrhage.ResultsTwenty studies, incorporating 5279 patients, were included. There was no evidence that rates of successful reperfusion differed in dMTE and IVT+MTE patients (sOR 0.93, 95% CI 0.68 to 1.28). In studies including IVT-IN dMTE patients, patients undergoing dMTE tended to have lower rates of functional independence and had higher odds for a fatal outcome as compared with IVT+MTE patients (sOR 0.78, 95% CI 0.61 to 1.01 and sOR 1.45, 95% CI 1.22 to 1.73). However, no such treatment group effect was found when analyses were confined to cohorts with a lower risk of selection bias (including IVT-E dMTE patients).ConclusionThe quality of evidence regarding the relative merits of IVT+MTE versus dMTE is low. When considering studies with lower selection bias, the data suggest that dMTE may offer comparable safety and efficacy as compared with IVT+MTE. The conduct of randomized-controlled clinical trials seems justified.
Impact of sex in stroke in the young Schwarzwald, Anina; Fischer, Urs; Seiffge, David ...
PloS one,
03/2023, Letnik:
18, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Limited data is available on sex differences in young stroke patients describing discrepant findings. This study aims to investigate the sex differences in young stroke patients.
Prospective cohort ...study comparing risk factors, etiology, stroke localization, severity on admission, management and outcome in patients aged 16-55 years with acute ischemic stroke consecutively included in the Bernese stroke database between 01/2015 to 12/2018 with subgroup analyses for very young (16-35y) and young patients (36-55y).
689 patients (39% female) were included. Stroke in women dominated in the very young (53.8%, p<0.001) and in men in the young (63.9%, p<0.001). As risk factors only sleep-disordered breathing was more predominant in men in the very young, whereas arterial hypertension, diabetes and atrial fibrillation did not differ in women and men older than 35y. The higher frequency of stroke in women in the very young may be explained by the sex specific risk factors such as pregnancy, puerperium, the use of oral contraceptives, and hormonal replacement therapy. Stroke severity at presentation, etiology, stroke localization, management, and outcome did not differ between women and men.
The main finding of this study is that sex specific risk factors in women may contribute to a large extent to the higher incidence of stroke in the very young in women. Important modifiable stroke risk factors, such as arterial hypertension, diabetes mellitus and atrial fibrillation did not differ in women and men, either in the young as well as in the very young. These findings have major implications for primary preventive strategies of stroke in young people.
Background and Purpose
Data on the management of large vessel occlusion in patients with anterior circulation acute ischemic stroke (AIS) due to underlying intracranial stenosis are scarce. The aim ...of this retrospective study was to compare endovascular treatment and outcome in AIS patients with and without underlying stenosis of the M1 segment.
Materials and Methods
A total of 533 acute stroke patients with an isolated M1 occlusion who underwent mechanical thrombectomy between 02/2010 and 08/2017 were included. Underlying intracranial atherosclerotic stenosis (ICAS) was present in 10 patients (1.9%), whereas 523 patients (98.1%) had an embolic occlusion without stenosis.
Results
There was no difference in age, admission National Institutes of Health Stroke Scale, risk factors, Alberta stroke program early CT score or collaterals between the groups. Procedure time (155 vs 40 min,
P
= 0.001) was significantly longer in the ICAS group where rescue stent-angioplasty was performed in all patients. There was no statistical difference in final modified thrombolysis in cerebral infarction score between both groups (70 vs 88%,
P
= 0.115). Favorable outcome (modified Rankin Scale ≤ 2) at 90 days was less frequent in patients with ICAS than in the embolic group (0 vs 49.4%,
P
= 0.004). The mortality rate tended to be higher in the ICAS group (44.4 vs 19.4%,
P
= 0.082).
Conclusion
In patients with AIS, rescue therapy with stent placement to treat underlying ICAS of the M1 segment is technically feasible; however, in our study, a significantly lower rate of favorable outcome was observed in these patients compared to those with thromboembolic M1 occlusions.
Level of Evidence
Level 3, non-randomized controlled study.
BACKGROUND AND PURPOSE:Post hoc analyses of randomized controlled clinical trials evaluating mechanical thrombectomy have suggested that admission-to-groin-puncture (ATG) delays are associated with ...reduced reperfusion rates. Purpose of this analysis was to validate this association in a real-world cohort and to find associated factors and confounders for prolonged ATG intervals.
METHODS:Patients included into the BEYOND-SWIFT cohort (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the Solitaire FR With the Intention for Thrombectomy; https://www.clinicaltrials.gov; Unique identifierNCT03496064) were analyzed (n=2386). Association between baseline characteristics and ATG was evaluated using mixed linear regression analysis. The effect of increasing symptom-onset-to-admission and ATG intervals on successful reperfusion (defined as Thrombolysis in Cerebral Infarction TICI 2b-3) was evaluated using logistic regression analysis adjusting for potential confounders.
RESULTS:Median ATG was 73 minutes. Prolonged ATG intervals were associated with the use of magnetic resonance imaging (+19.1 95% CI, +9.1 to +29.1 minutes), general anesthesia (+12.1 95% CI, +3.7 to +20.4 minutes), and borderline indication criteria, such as lower National Institutes of Health Stroke Scale, late presentations, or not meeting top-tier early time window eligibility criteria (+13.8 95% CI, +6.1 to +21.6 minutes). There was a 13% relative odds reduction for TICI 2b-3 (adjusted odds ratio aOR, 0.87 95% CI, 0.79–0.96) and TICI 2c/3 (aOR, 0.87 95% CI, 0.79–0.95) per hour ATG delay, while the reduction of TICI 2b-3 per hour increase symptom-onset-to-admission was minor (aOR, 0.97 95% CI, 0.94–0.99) and inconsistent regarding TICI 2c/3 (aOR, 0.99 95% CI, 0.97–1.02). After adjusting for identified factors associated with prolonged ATG intervals, the association of ATG delay and lower rates of TICI 2b-3 remained tangible (aOR, 0.87 95% CI, 0.76–0.99).
CONCLUSIONS:There is a great potential to reduce ATG, and potential targets for improvement can be deduced from observational data. The association between in-hospital delay and reduced reperfusion rates is evident in real-world clinical data, underscoring the need to optimize in-hospital workflows. Given the only minor association between symptom-onset-to-admission intervals and reperfusion rates, the causal relationship of this association warrants further research.
REGISTRATION:URLhttps://www.clinicaltrials.gov. Unique identifierNCT03496064.
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