Fatigue is a disabling and persistent symptom affecting many stroke survivors and is a predictor for death after stroke onset. Post-stroke fatigue is a multidimensional motor-perceptive, emotional ...and cognitive experience that has become of interest for stroke researchers only in the recent past. More studies are still needed to understand the pathophysiology, clinical characteristics, associated factors and best treatment strategy. The aim of this narrative review was to provide a comprehensive knowledge, from current literature, regarding the epidemiology, clinical characteristics and treatment of fatigue in order to provide physicians with better tools for treating this debilitating symptom that worsens outcome.
Background and Purpose Substantial uncertainty exists on the benefit of organizational paradigms in stroke networks. Here we systematically reviewed and meta-analyzed data from studies comparing ...functional outcome between the mothership (MS) and the drip and ship (DS) models.Methods The meta-analysis protocol was registered international prospective register of systematic reviews (PROSPERO) and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, and Cochrane Central databases were searched for randomized-controlled clinical trials (RCTs), retrospective and prospective studies comparing MS versus DS. Primary endpoints were functional independence at 90 days (modified Rankin Scale <3) and successful recanalization (Thrombolysis in Cerebral Infarction Scale TICI >2a); secondary endpoints were 3-month mortality and symptomatic intracranial haemorrhage (sICH). Odds ratios for endpoints were pooled using the random effects model and were compared between the two organizational models.Results Overall, 18 studies (n=7,017) were included in quantitative synthesis. MS paradigm was superior to DS model for functional independence (odds ratio, 1.34; 95% confidence interval, 1.16 to 1.55; I2=30%). Meta-regression analysis revealed association between onset-to-needle time and good functional outcome, with longer onset-to-needle time being detrimental. Similar rates of recanalization, sICH and mortality at 90 days were documented between MS and DS.Conclusions Patients with acute ischemic stroke eligible for reperfusion strategies might benefit more from MS paradigm as compared to DS. RCTs are needed to further refine best management taking into account logistics, facilities and resources.
Secondary prevention of atherosclerotic stroke and transient ischemic attack includes both conventional approaches to vascular risk factor management (blood pressure lowering, cholesterol reduction ...with statins and smoking cessation), antiplatelet therapy and more specific interventions, such as carotid revascularization. The objective of this review is to discuss effective interventions for optimal secondary prevention of atherosclerotic stroke.
Objectives
Aim of this study was to evaluate the association between cerebral microbleeds (CMBs) and white matter disease (WMD) with intracerebral hemorrhage (ICH) after intravenous thrombolysis ...(IVT) with rt-PA. We also evaluated whether CMBs characteristics and WMD burden correlate with symptomatic ICH and outcome.
Methods
We included acute ischemic stroke (AIS) patients treated with IVT. The number and location of CMBs as well as severity of WMD were rated analyzing pre- or post-treatment MRI. Multivariable regression analysis was used to determine the impact of CMB and WMD on ICH subgroups and outcome measures.
Results
434 patients were included. CMBs were detected in 23.3% of them. ICH occurred in 34.7% of patients with CMBs. Independent predictors of parenchymal hemorrhage were the presence of CMBs (OR 2.724, 95% CI 1.360–5.464,
p
= 0.005) as well as cortical-subcortical stroke (OR 3.629, 95% CI 1.841–7.151,
p
< 0.001) and atherothrombotic stroke subtype (OR 3.381, 95% CI 1.335–8.566,
p
= 0.010). Either the presence, or number, and location of CMBs, as well as WMD, was not independently associated with the development of SICH. No independent association between the presence, number, or location of CMBs or WMD and outcome measures was observed.
Conclusions
The results of our study suggest that the exclusion of eligible candidates to administration of IV rt-PA only on the basis of CMBs presence is not justified. The clinical decision should be weighed with a case-by-case approach. Additional data are needed to evaluate the benefit-risk profile of rt-PA in patients carrying numerous microbleeds.
Carotid stenosis is generally associated with high risks of stroke and vascular events. In asymptomatic and symptomatic patients, with or without revascularization, optimal managements of carotid ...artery stenosis require the use of medications or lifestyle modifications (stopping smoking and monitoring hypertension, hyperlipidemia, and diabetes) to control the processes associated with atheroma to reduce the risk of embolic events. Moreover, antiplatelet therapy should be considered. There is little evidence that antiplatelet therapy is beneficial in preventing stroke or the progression of stenosis in asymptomatic patients, whereas, evidence of a benefit from antiplatelet therapy for secondary prevention of recurrent stroke in symptomatic patients with carotid atherosclerosis is more robust. Also, in patients undergoing carotid endarterectomy, perioperative antithrombotic therapy should include aspirin, while the addition of clopidogrel should be decided case-by-case. Furthermore, perioperative antithrombotic therapy in patients undergoing carotid stenting should consist a combination of aspirin plus clopidogrel.
Perioperative stroke is an ischemic or hemorrhagic cerebrovascular accident that can arise intraoperatively or from 3 to 30 days after surgery. This relatively rare complication deserves attention ...because of its high mortality and serious disability, the latter of which can lead to prolonged hospital stay as well as discharge to long-term care facilities. The aim of this article was to review the literature on perioperative stroke in general surgery, excluding carotid and cardiac surgeries because these have already been thoroughly investigated in previous papers.
A search strategy was designed to identify all relevant studies on perioperative stroke in the English language. This search was restricted to papers published up to December 5, 2011. Studies were initially identified from the Medline/PubMed database, EMBASE and the Cochrane Database using the search terms 'surgery', 'perioperative stroke', 'risk factors', 'anticoagulation treatment' and 'antiplatelet treatment'.
The incidence of perioperative stroke among patients who undergo nonvascular surgery is reported to be about 0.08-0.7%. This depends on the type and complexity of the surgical procedure along with patient risk factors. The reported perioperative mortality is 18-26%. One of the main issues is the management of patients taking anticoagulant or antiplatelet drugs, as the risk of bleeding has to be counterbalanced with the risk of arterial thrombosis due to discontinuation. Additionally, the presence of symptomatic carotid stenosis should be taken into account in the risk evaluation.
To date, current guidelines are incomplete regarding the management of patients with vascular disease undergoing nonvascular surgery. It is recommended to stop oral anticoagulation approximately 5 days before major surgery to adequately allow the INR to normalize, and at the same time subcutaneous low-molecular-weight heparin or intravenous unfractionated heparin should be started. Regarding new anticoagulants, dabigatran does not need to be withheld for minor procedures. Currently, there are no clear recommendations on the use of rivaroxaban and apixaban. Data concerning the management of patients undergoing antiplatelet therapy are lacking. To date, neurologists discourage the perioperative withdrawal of aspirin (acetylsalicylic acid, ASA) especially in patients in secondary prevention. The 'Antiplatelet Agents in the Perioperative Management of Patients Trial' is ongoing to assess the safety and determine the optimal use of ASA in the perioperative management of patients undergoing general and abdominal surgery. In the meantime an individualized, accurate, multidisciplinary (surgical, neurological, cardiological and anesthesiological) risk/benefit assessment remains the best basis for treatment decision.
The association between stroke and cancer is well-known but insufficiently investigated. Aim of this multicentre retrospective cohort study was to estimate the prevalence of cancer-associated ...ischemic stroke, describe clinical outcomes in patients with cancer-associated ischemic stroke and investigate independent factors associated with active cancer.
Consecutive adult patients admitted for acute ischemic stroke were included. Included patients were admitted in the Stroke Unit of the Hospital of Perugia, Italy, from March 2005 to March 2015, and in a medical unit of the Hospital of Varese, Italy, from January 2010 till December 2011. Clinical and laboratory data of patients with and without active cancer were collected. Multivariate logistic regression analysis was performed to identify independent factors associated with active cancer.
A total of 2209 patients admitted with acute ischemic stroke were included with a median hospital stay of 9 days (interquartile range 5.75–14). Mean age was 72.7 years (standard deviation +/− 13); 55% patients were male and 4.4% had active cancer. Factors significantly associated with the presence of active cancer were age > 65 years (odds ratio OR 3.34; 95% confidence interval CI 1.64–6.81), occurrence of venous thromboembolism VTE (OR 2.84; 95% CI 1.12–7.19), low-density lipoprotein (LDL) cholesterol level < 70 mg/dL (OR 1.92; 95% CI 1.06–3.47), cryptogenic stroke subtype (OR 1.93; 95% CI 1.22–3.04). Overall mortality rate during hospital stay was greater in patients with active cancer (21.5% vs. 10% P < 0.05).
Older age, occurrence of VTE, low LDL level, and cryptogenic stroke subtype, are independently associated with active cancer. Overall, our findings suggest a possible prevalent role of hypercoagulability in the pathogenesis of cancer-associated ischemic stroke.
•The prevalence of active cancer in ischemic stroke patients was 4.4%.•Low LDL cholesterol values associated to active cancer suggest a cancer-related ischemic stroke different characteristics.•Cryptogenic stroke and VTE associated to active cancer suggest a role of cancer-related ischemic stroke hypercoagulability.
Introduction
Despite intravenous thrombolysis (IVT) and endovascular treatment (EVT) have been demonstrated effective in acute ischemic stroke (AIS) due to large vessel occlusions, there are still no ...conclusive data to guide treatment in stroke due to cervical internal carotid artery (ICA) occlusion. We systematically reviewed available literature to compare IVT, EVT, and bridging (IVT + EVT) and define optimal treatment.
Methods
Systematic review followed predefined protocol (Open-Science-Framework
osf.io/bfykj
). MEDLINE, EMBASE, and Cochrane CENTRAL were searched. Results were restricted to studies in English, with sample size ≥ 10 and follow-up ≥30 days. Primary outcomes were favorable outcome (mRS ≤ 2), mortality, and symptomatic intracerebral hemorrhage(sICH), defined according to study original report. Newcastle-Ottawa scale was used for bias assessment.
Results
Seven records of 930 screened were included in meta-analysis. Quality of studies was low-to-fair in 5, good in 2. IVT (
n
= 450) did not differ for favorable outcome and mortality compared to EVT (
n
= 150), though having lower rate of sICH (OR = 0.4, 95% CI 0.2–0.8). Compared to IVT, bridging (IVT + EVT) was associated with higher rate of favorable outcome (OR = 2.2, 95% CI 1.3–3.7). Compared to EVT, bridging (IVT + EVT) provided higher rate of favorable outcome (OR = 1.9, 95% CI 1.1–3.4), with a marginally increased risk of sICH (OR = 2.1, 95% CI 1–4.4) but similar mortality rates.
Conclusions
Our systematic review highlights that, in acute ischemic stroke associated with isolated cervical ICA occlusion, bridging (IVT + EVT) might lead to higher rate of functional independence at follow-up, without increasing mortality. The low quality of available studies prevents from drawing firm conclusions, and randomized-controlled clinical trials are critically needed to define optimal treatment in this AIS subgroup.
PDF
