Background and purpose
In contrast to anterior circulation stroke (ACS), there is no evidence from randomized trials that mechanical thrombectomy (MT) with modern stent retrievers or ...thromboaspiration is safe and effective in posterior circulation stroke (PCS).
Methods
The present analysis was based on the prospective multicentre Registry on Revascularization in Ischemic Stroke Patients (REVASK) in Germany. Demographic data, periprocedural times and complications, recanalization rates, and functional outcome at discharge and after 3 months were compared between 139 consecutive patients with PCS (84.9% basilar artery, 16.5% vertebral artery and 4.3% posterior cerebral artery occlusion) and 961 patients with ACS treated with MT.
Results
Compared to ACS, PCS patients were significantly younger (65 vs. 69 years, P = 0.021) and had a lower median National Institutes of Health Stroke Scale (NIHSS) score at baseline (12 vs. 15, P = 0.024). Patients with PCS had a significantly longer time delay between symptom onset and both start and end of the MT procedure. Successful recanalization and thrombectomy passes did not significantly differ between the two groups. No symptomatic intracranial haemorrhage occurred in PCS compared to 3% in ACS (P = 0.010). The median NIHSS score at discharge was 3 in PCS and 4 in ACS. Favourable functional outcome at 3 months (modified Rankin Scale 0–2 38.0% vs. 42.6%, P = 0.392) and mortality (33.7% vs. 30.8%, P = 0.539) did not differ significantly between PCS and ACS.
Conclusions
The study suggests that MT in PCS shows a lower risk of symptomatic intracranial haemorrhage and similar effectiveness compared to ACS. PCS patients also seem to benefit from MT started beyond 6 h after symptom onset.
C-reactive protein is a marker of inflammation and vascular disease. It also seems to be associated with an increased risk of dementia. To better understand potential underlying mechanisms, we ...assessed microstructural brain integrity and cognitive performance relative to serum levels of high-sensitivity C-reactive protein (hs-CRP).
We cross-sectionally examined 447 community-dwelling and stroke-free individuals from the Systematic Evaluation and Alteration of Risk Factors for Cognitive Health (SEARCH) Health Study (mean age 63 years, 248 female). High-field MRI was performed in 321 of these subjects. Imaging measures included fluid-attenuated inversion recovery sequences for assessment of white matter hyperintensities, automated quantification of brain parenchyma volumes, and diffusion tensor imaging for calculation of global and regional white matter integrity, quantified by fractional anisotropy (FA). Psychometric analyses covered verbal memory, word fluency, and executive functions.
Higher levels of hs-CRP were associated with worse performance in executive function after adjustment for age, gender, education, and cardiovascular risk factors in multiple regression analysis (beta = -0.095, p = 0.02). Moreover, higher hs-CRP was related to reduced global fractional anisotropy (beta = -0.237, p < 0.001), as well as regional FA scores of the frontal lobes (beta = -0.246, p < 0.001), the corona radiata (beta = -0.222, p < 0.001), and the corpus callosum (beta = -0.141, p = 0.016), in particular the genu (beta = -0.174, p = 0.004). We did not observe a significant association of hs-CRP with measures of white matter hyperintensities or brain atrophy.
These data suggest that low-grade inflammation as assessed by high-sensitivity C-reactive protein is associated with cerebral microstructural disintegration that predominantly affects frontal pathways and corresponding executive function.
Background and purpose
Since early treatment of acute stroke is associated with an improved outcome, emergency medical service (EMS) transport of stroke patients is recommended. It remains unclear, ...however, whether EMS transport leads to faster treatment. The impact of the transport mode on pre‐ and in‐hospital processes of care was therefore investigated.
Methods
The present study was based on a prospective database of 158 hospitals of the Stroke Register of Northwestern Germany, which included 162 511 stroke patients admitted between January 2010 and December 2011. Main outcome measures were the baseline characteristics associated with EMS transport and process‐of‐care indicators according to the transport mode.
Results
Overall, 101 850 (72.0%) patients were transported by EMS and 39 324 (28.0%) by self‐transport. The baseline characteristics showing the strongest associations with EMS use were the care situation institutional care, adjusted odds ratio (OR) 7.81; 95% CI 6.86–8.90, a disturbed level of consciousness (adjusted OR 3.00; 95% CI 2.59–3.48) and having a subarachnoid (adjusted OR 2.79; 95% CI 2.24–3.49) or intracerebral hemorrhage (adjusted OR 2.26; 95% CI 1.92–2.67). For self‐transport patients the probability of being in a higher onset‐to‐door time category was 4.36 (95% CI 4.26–4.47) and the probability of being in a higher door‐to‐imaging time category was 1.32 (95% CI 1.28–1.36). Compared with self‐transport, EMS transport was independently associated with thrombolysis (adjusted OR 1.95, 95% CI 1.77–2.15).
Conclusions
Patient transport with EMS was independently associated with faster hospital arrival and shorter time periods from hospital admission to brain imaging and to the frequency of thrombolysis.
Background
Sleep disorders are highly prevalent in the general population and may be linked in a bidirectional fashion to stroke, which is one of the leading causes of morbidity and mortality.
Aim
...Four major scientific societies established a task force of experts in neurology, stroke, respiratory medicine, sleep medicine and methodology to critically evaluate the evidence regarding potential links and the impact of therapy.
Materials and methods
Thirteen research questions were evaluated in a systematic literature search using a stepwise hierarchical approach: first, systematic reviews and meta‐analyses; second, primary studies post‐dating the systematic reviews/meta‐analyses. A total of 445 studies were evaluated and 88 were included. Statements were generated regarding current evidence and clinical practice.
Results
Severe obstructive sleep apnoea (OSA) doubles the risk for incident stroke, especially in young to middle‐aged patients. Continuous positive airway pressure (CPAP) may reduce stroke risk, especially in treatment‐compliant patients. The prevalence of OSA is high in stroke patients and can be assessed by polygraphy. Severe OSA is a risk factor for recurrence of stroke and may be associated with stroke mortality, whilst CPAP may improve stroke outcome. It is not clear if insomnia increases stroke risk, whilst the pharmacotherapy of insomnia may increase it. Periodic limb movements in sleep (PLMS), but not restless limb syndrome (RLS), may be associated with an increased risk of stroke. Preliminary data suggest a high frequency of post‐stroke insomnia and RLS and their association with a less favourable stroke outcome, whilst treatment data are scarce.
Discussion/Conclusion
Overall, the evidence base is best for OSA relationship with stroke and supports active diagnosis and therapy. Research gaps remain especially regarding insomnia and RLS/PLMS relationships with stroke.
Patients with ischaemic stroke are at risk of recurrent stroke. In this study, we aimed to compare the effect of a structured ambulatory post-stroke care programme versus usual care on recurrent ...vascular events and death and control of cardiovascular risk factors.
We did a prospective, open-label, cluster-randomised controlled trial (SANO) at stroke centres in regions of Germany. A cluster was defined as a region in which acute stroke care is provided by a participating stroke centre. Patients were eligible for participation if they were aged 18 years or older, had no severe disabilities before the index stroke (modified Rankin scale 0–1), had at least one modifiable cardiovascular risk factor, and presented within 14 days of symptom onset of their first ischaemic stroke. The participating regions were randomly assigned (1:1) to the intervention and control group (usual care) by the statistician using block randomisation (block sizes of six), stratified by rural and urban regions. In intervention regions, a cross-sectoral multidisciplinary network was established to provide a 1-year organisational and patient-centred intervention. Due to the type of intervention, masking of participants and study physicians was not possible. Endpoint adjudication was performed by an independent endpoint adjudication committee who were masked to cluster allocation. The primary endpoint was a composite of recurrent stroke, myocardial infarction, and all-cause death within 12 months after baseline assessment, assessed in the modified intention-to-treat (mITT) population, which included all patients who did not withdraw consent and completed the primary endpoint assessment at 12 months. This study was registered with the German Clinical Trials Register, DRKS00015322.
Between Jan 1, 2019 and Dec 22, 2020, 36 clusters were assessed for eligibility, of which 30 were randomly assigned to the intervention group (n=15 clusters) or control group (n=15 clusters). No clusters dropped out of the study. 1203 (86%) of 1396 enrolled patients in the intervention group and 1283 (92%) of 1395 enrolled patients in the control group were included in the mITT population. The primary endpoint was confirmed in 64 (5·3%) of 1203 patients in the intervention group and 80 (6·2%) of 1283 patients in the control group (unadjusted odds ratio OR 0·80 95% CI 0·49–1·30; adjusted OR aOR 0·95 95% CI 0·54–1·67). All-cause deaths occurred in 31 (2·4%) of 1203 patients in the intervention group and 12 (1·0%) of 1283 patients in the control group. The incidence of serious adverse events was higher in the intervention group (266 23·1% of 1151) than the control group (106 9·2% of 1152). Falls (134 11·4% of 1203 patients in the intervention group; 39 3·3% of 1152 patients in the control group), hypertensive crisis (55 4·7%; 34 2·8%), and diagnosis of depression (51 4·3%; 13 1·1%) were the most frequent adverse events in both groups. No differences were identified in the rate of readmission to hospital between groups.
No differences were identified between patients with ischaemic stroke in the intervention group and control group with regard to the incidence of vascular events 1 year after baseline assessment, despite positive effects with regard to the control of some cardiovascular risk factors. Longer-term effects and other potentially favourable effects on stroke-related sequelae and quality of life require further evaluation.
Innovation Fund of the Federal Joint Committee.
Background and purpose
Detection of occult atrial fibrillation (AF) is crucial for optimal secondary prevention in stroke patients. The AF detection rate was determined by implantable cardiac monitor ...(ICM) and compared to the prediction rate of the probability of incident AF by software based analysis of a continuously monitored electrocardiogram at follow‐up (stroke risk analysis, SRA); an optimized AF detection algorithm is proposed by combining both tools.
Methods
In a monocentric prospective study 105 out of 389 patients with cryptogenic stroke despite extensive diagnostic workup were investigated with two additional cardiac monitoring tools: (a) 20 months’ monitoring by ICM and (b) SRA during hospitalization at the stroke unit.
Results
The detection rate of occult AF was 18% by ICM (n = 19) (range 6–575 days) and 62% (n = 65) had an increased risk for AF predicted by SRA. When comparing the predictive accuracy of SRA to ICM, the sensitivity was 95%, specificity 35%, positive predictive value 27% and negative predictive value 96%. In 18 patients with AF detected by ICM, SRA also showed a medium risk for AF. Only one patient with a very low risk predicted by SRA developed AF revealed by ICM after 417 days.
Conclusions
A combination of SRA and ICM is a promising strategy to detect occult AF. SRA is reliable in predicting incident AF with a high negative predictive value. Thus, SRA may serve as a cost‐effective pre‐selection tool identifying patients at risk for AF who may benefit from further cardiac monitoring by ICM.
Background and purpose
Post‐ischaemic immune cell invasion into the brain is well characterized in animal stroke models and contributes to neuronal damage. Therefore, it represents a promising ...therapeutic target. Cerebrospinal fluid (CSF) is easily accessible and may reflect cellular events within the parenchyma. However, comprehensive studies on CSF immune cells in patients with stroke are lacking.
Methods
In a retrospective cohort study, we performed extensive immune‐cell profiling in CSF and peripheral blood of patients with acute ischaemic stroke and healthy controls. In patients with stroke, infarct size was quantified on follow‐up imaging.
Results
Overall, 90 patients with ischaemic stroke and 22 controls were included in our study. After stroke, the total protein was increased (537.3 vs. 353.2 mg/L, P = 0.008) and the mean total white cell count was slightly but non‐significantly elevated (1.76 vs. 0.50 cells/μL, P = 0.059). Proportions of CSF lymphocytes, monocytes and granulocytes and their respective subsets did not differ between patients with stroke and controls. In addition, there were no associations between proportions of major leukocyte subsets in CSF and the time from symptom onset to CSF sampling, infarct size or infarct localization.
Conclusions
Ischaemic stroke induces only a very slight increase of CSF immune cells without changes in the composition of immune cell subsets, thus indicating that parenchymal inflammation is not sufficiently reflected in the CSF. Our findings suggest that CSF is not a major invasion route for immune cells and that CSF cell analyses are not suitable as biomarkers to guide future immune therapies for stroke.
Longitudinal studies on cognitive outcomes after stroke revealed heterogeneous results and the underlying pathology and risk factors for so-called post-stroke dementia are unclear.
To assess ...long-term cognitive performance changes in patients after the first ischemic stroke and to evaluate possible risk factors for post-stroke dementia.
In this study 66 clinically mildly affected patients aged 54-87 years without a history of dementia underwent extensive neuropsychological assessment after first ever ischemic stroke and again 6 months after the event (follow-up assessment). Demographic, clinical and paraclinical parameters were assessed as potential predictors for long-term cognitive outcome.
At the group level significant performance improvements were found for most of the neurocognitive domains at the follow-up assessment. The greatest cognitive improvement was found in visuospatial processing. Immediately after stroke 54.5% of patients were considered cognitively impaired (z-scores < -2 in at least 2 neurocognitive domains). At follow-up only 16.7% were considered cognitively impaired according to this criterion and among these only 2 patients (3%) had developed a new, clinically relevant cognitive impairment (i.e. post-stroke dementia). Patients with inferior cognitive performance improvements at follow-up had on average larger brain lesions caused by the stroke as well as a prediabetic metabolic status.
The probability of developing a post-stroke dementia syndrome is lower than previously assumed in patients with first ever stroke, with only mild clinical disability and without premorbid cognitive impairment. Long-term cognitive impairment could primarily be determined by the size of the lesioned brain area as well as the premorbid (pre)diabetic status.
Background
The increasing use of endovascular treatments has led to higher recanalization rates and better clinical outcomes compared with intravenous thrombolysis alone. Stent retrievers represent ...the latest development for recanalization of large vessel occlusions. Decompressive hemicraniectomy has proved beneficial in patients suffering from rising intracranial pressure after malignant stroke.
Aims and/or Hypothesis
We investigated the effect of the implementation of stent retriever treatment on the frequency of hemicraniectomy as a surrogate marker for infarct size and thus for poor neurological outcome.
Methods
Patients with acute ischemic stroke were retrospectively studied. We compared the frequency of hemicraniectomy following proximal artery occlusion of the internal carotid artery and middle cerebral artery main stem in the years before (2009 and 2010) and after (2012 and 2013) introducing stent retrievers.
Results
Overall, 497 patients with proximal arterial occlusion were included in the study. Of 253 patients admitted in the years 2009 and 2010 44 (17.4 %) and of 244 patients admitted in 2012 and 2013, 20 (8.2 %) received a hemicraniectomy. This decrease in the proportion of hemicraniectomies was statistically significant (
p
< 0.01).
Conclusions
The findings in this study illustrate a significantly reduced rate of hemicraniectomies in patients with proximal artery occlusions after implementation of thrombectomy with stent retriever. Hereby, we could show a significant reduction of malignant infarctions after thrombectomy with stent retriever.
ObjectivesInfections in patients with stroke are common and significantly affect outcome. Various predictors of poststroke infections were determined, such as degree of neurological impairment and ...implementation of therapeutic interventions. The authors investigated whether stroke location and stroke size are independent risk factors for poststroke infections.Methods591 patients with acute stroke who were treated on our stroke unit were included in a prospective observational study. Predefined endpoints were pneumonia, urinary-tract infection (UTI) and other infections. The OR of infections was calculated for various stroke locations, stroke lateralisation and three categories of stroke size. Logistic regression models were used to adjust for factors significantly associated with poststroke infections in a single-factor analysis.ResultsIn the single-factor analysis, the left anterior cerebral artery territory was associated with pneumonia. After adjustment for relevant covariates, this association was no longer statistically significant. Stroke lateralisation showed no association with infection frequency. The largest stroke size was positively associated with pneumonia (OR 3.5, p<0.001). The smallest lesion size was significantly less associated with the occurrence of UTI (OR 0.4, p<0.01).ConclusionIn this study, lesion size is an independent risk factor for the development of poststroke infection. Particular brain regions associated with infections could not be determined.
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