This study aimed to assess if there are sex differences in the functional outcome of intravenous thrombolysis (IVT) among patients with lacunar stroke (LS).
Consecutive patients admitted from 1 ...January 2014 to 31 January 2020 to hospitals participating in the Swiss Stroke Registry presenting with LS and treated with IVT were included. The study population was then divided into two groups based on patient sex, and a multivariable ordinal logistic regression analysis was performed to uncover sex differences in the modified Rankin Scale (mRS) score at 90 days after stroke.
A total of 413 patients with LS were treated with IVT: 177 (42.9%) women and 236 (57.1%) men. Women were older than men (median age 74 years, 25th-75th percentiles 67-84 years versus 70 years, 25th-75th percentiles 60-80 years, value of p 0.001) and, after adjustment for meaningful variables, showed more frequently increased odds of a higher mRS score at 90 days after stroke (adjusted odds ratio 1.49, 95% confidence interval 1.01-2.19, value of p 0.044).
This study showed that female sex increased the odds of a worse functional response to IVT in patients with LS. Future studies should further elucidate the mechanisms underlying such sex differences.
Central retinal artery occlusion (CRAO) often leads to permanent monocular blindness. Hence, early recognition and rapid re-perfusion is of paramount importance. This study aims to describe ...prehospital pathways in CRAO compared to stroke and study the knowledge about CRAO.
(1) Description of baseline characteristics, prehospital pathways/delays, and acute treatment (thrombolysis/thrombectomy vs. standard of care) of patients with CRAO and ischemic stroke registered in the Swiss Stroke Registry. (2) Online survey about CRAO knowledge amongst population, general practitioners (GPs) and ophthalmologists in Eastern Switzerland.
Three hundred and ninety seven CRAO and 32,816 ischemic stroke cases were registered from 2014 until 2019 in 20 Stroke Centers/Units in Switzerland. In CRAO, 25.6% arrived at the hospital within 4 h of symptom onset and had a lower rate of emergency referrals. Hence, the symptom-to-door time was significantly longer in CRAO compared to stroke (852 min. vs. 300 min). The thrombolysis/thrombectomy rate was 13.2% in CRAO and 30.9% in stroke. 28.6% of the surveyed population recognized CRAO-symptoms, 55.4% of which would present directly to the emergency department in contrast to 90.0% with stroke symptoms. Almost 100% of the ophthalmologist and general practitioners recognized CRAO as a medical emergency and 1/3 of them considered IV thrombolysis a potentially beneficial therapy.
CRAO awareness of the general population and physician awareness about the treatment options as well as the non-standardized prehospital organization, seems to be the main reason for the prehospital delays and impedes treating CRAO patients. Educational efforts should be undertaken to improve awareness about CRAO.
Matrix metalloproteinases (MMPs), a family of zinc‐dependent endoproteinases, are effector molecules in the breakdown of the blood–brain and blood–nerve barrier, and promote neural tissue invasion by ...leukocytes in inflammatory diseases of the central and peripheral nervous systems. Moreover, MMPs play an important role in synaptic remodeling, neuronal regeneration, and remyelination. Recent work concerning MMPs in patients with neuropathy, myopathy, spinal cord injury, and amyotrophic lateral sclerosis (ALS), and in corresponding animal models, is discussed in this review. Muscle Nerve, 2007
Acute stroke treatment has advanced substantially over the last years. Important milestones constitute intravenous thrombolysis, endovascular therapy (EVT), and treatment of stroke patients in ...dedicated units (stroke units). At present in Switzerland there are 13 certified stroke units and 10 certified EVT-capable stroke centers. Emerging challenges for the prehospital pathways are that (i) acute stroke treatment remains very time sensitive, (ii) the time window for acute stroke treatment has opened up to 24 h in selected cases, and (iii) EVT is only available in stroke centers. The goal of the current guideline is to standardize the prehospital phase of patients with acute stroke for them to receive the optimal treatment without unnecessary delays. Different prehospital models exist. For patients with large vessel occlusion (LVO), the Drip and Ship model is the most commonly used in Switzerland. This model is challenged by the Mothership model where stroke patients with suspected LVO are directly transferred to the stroke center. This latter model is only effective if there is an accurate triage by paramedics, hence the patient may benefit from the right treatment in the right place, without loss of time. Although the Cincinnati Prehospital Stroke Scale is a well-established scale to detect acute stroke in the prehospital setting, it neglects nonmotor symptoms like visual impairment or severe vertigo. Therefore we suggest “acute occurrence of a focal neurological deficit” as the trigger to enter the acute stroke pathway. For the triage whether a patient has a LVO (yes/no), there are a number of scores published. Accuracy of these scores is borderline. Nevertheless, applying the Rapid Arterial Occlusion Evaluation score or a comparable score to recognize patients with LVO may help to speed up and triage prehospital pathways. Ultimately, the decision of which model to use in which stroke network will depend on local (e.g. geographical) characteristics.
Six patients with chronic acquired demyelinating neuropathy (CADP) were treated with autologous peripheral blood stem cell transplantation (PBSCT). Two with polyneuropathy, organomegaly, ...endocrinopathy, M‐protein, and skin changes (POEMS) syndrome improved–improvement was sustained in one but relapsed and required repeat transplant in the other. Two of the three with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and one with an IgM paraprotein and antibodies to nerve improved–of the responders, one relapsed after 18 months and the other was in remission after 6 months. Four developed neutropenic septicemia and pneumonia. The role of PBSCT in CADP refractory to other treatment deserves further investigation but the serious adverse events and lack of sustained response in some patients emphasize the need for caution.
Objective
The aim was to evaluate, in patients with atrial fibrillation (AF) and acute ischemic stroke, the association of prior anticoagulation with vitamin K antagonists (VKAs) or direct oral ...anticoagulants (DOACs) with stroke severity, utilization of intravenous thrombolysis (IVT), safety of IVT, and 3‐month outcomes.
Methods
This was a cohort study of consecutive patients (2014–2019) on anticoagulation versus those without (controls) with regard to stroke severity, rates of IVT/mechanical thrombectomy, symptomatic intracranial hemorrhage (sICH), and favorable outcome (modified Rankin Scale score 0–2) at 3 months.
Results
Of 8,179 patients (mean SD age, 79.8 9.6 years; 49% women), 1,486 (18%) were on VKA treatment, 1,634 (20%) on DOAC treatment at stroke onset, and 5,059 controls. Stroke severity was lower in patients on DOACs (median National Institutes of Health Stroke Scale 4, interquartile range 2–11) compared with VKA (6, 2–14) and controls (7, 3–15, p < 0.001; quantile regression: β −2.1, 95% confidence interval CI −2.6 to −1.7). The IVT rate in potentially eligible patients was significantly lower in patients on VKA (156 of 247 63%; adjusted odds ratio aOR 0.67; 95% CI 0.50–0.90) and particularly in patients on DOACs (69 of 464 15%; aOR 0.06; 95% CI 0.05–0.08) compared with controls (1,544 of 2,504 74%). sICH after IVT occurred in 3.6% (2.6–4.7%) of controls, 9 of 195 (4.6%; 1.9–9.2%; aOR 0.93; 95% CI 0.46–1.90) patients on VKA and 2 of 65 (3.1%; 0.4–10.8%, aOR 0.56; 95% CI 0.28–1.12) of those on DOACs. After adjustments for prognostic confounders, DOAC pretreatment was associated with a favorable 3‐month outcome (aOR 1.24; 1.01–1.51).
Interpretation
Prior DOAC therapy in patients with AF was associated with decreased admission stroke severity at onset and a remarkably low rate of IVT. Overall, patients on DOAC might have better functional outcome at 3 months. Further research is needed to overcome potential restrictions for IVT in patients taking DOACs. ANN NEUROL 2021;89:42–53
Abstract only Introduction: Endovascular treatment (EVT), in particular mechanical thrombectomy, has dramatically improved the clinical outcome of patients with large vessels occlusion (LVO) of the ...anterior circulation. In contrast, the benefits of EVT cannot be applied to lacunar strokes (LS). The absence of a LVO in LS has been historically associated with a more favorable outcome, but in the new era of EVT, this assumption may not be correct anymore. We aimed to test the general assumption that LS have a better prognosis than other stroke subtypes, and analyze the outcome of LS treated with IVT as compared to strokes with LVO treated with IVT and/or mechanical thrombectomy in the multicentric Swiss Stroke Registry. Methods: retrospective propensity score matching analysis of patients from the Swiss stroke registry (SSR) with lacunar stroke treated with thrombolysis versus LVO of the medial cerebral artery treated with EVT (with or without thrombolysis). Primary endpoint was a shift analysis of mRs at 90 days after stroke. Secondary outcomes were favorable functional outcome (mRS 0-1), independence (mRS 0-2), survival with high disability (mRS 3-5) and mortality (mRS 6) at 90 days. Results: From 13'227 patients, the propensity score method matched (sex, age, NIHSS, time to treatment, prior anticoagulation, pre-stroke modified Rankin Score, mRs) 538 patients (269 in each group. There was no difference between groups in mRs shift analysis at 90 days after stroke (OR=0.99, 95%CI=0.73-1.35, p=0.952). There was also no significant difference in mRS 0-1 (59.9% vs 55.8% respectively; OR=0.79, 95%CI=0.55-1.16, p=0.75). LS+IVT patients showed a non-significant trend towards mRS 3-5 (OR=1.23, 95%CI=0.78-1.94, p=0.38), while patients treated with EVT had a slightly, non-significant, higher mortality (6.3% vs 1.9%, p=0.38). Conclusions: Lacunar strokes - which cannot directly benefit from thrombectomy therapy - when treated with IVT and matched on key prognostic variables, seem to have similar outcomes as LVO strokes treated with EVT. This observation confirms that lacunar stroke is not a benign entity and therefore suggests that reperfusion therapy should be addressed with the same intensity as LVO stroke.
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