Infarct in a new territory (INT) is a known complication of endovascular stroke therapy. We assessed the incidence of INT, outcomes after INT, and the impact of concurrent treatments with intravenous ...thrombolysis and nerinetide.
Data are from ESCAPE-NA1 trial (Safety and Efficacy of Nerinetide NA-1 in Subjects Undergoing Endovascular Thrombectomy for Stroke), a multicenter, international randomized study that assessed the efficacy of intravenous nerinetide in subjects with acute ischemic stroke who underwent endovascular thrombectomy within 12 hours from onset. Concurrent treatment and outcomes were collected as part of the trial protocol. INTs were identified on core lab imaging review of follow-up brain imaging and defined by the presence of infarct in a new vascular territory, outside the baseline target occlusion(s) on follow-up brain imaging (computed tomography or magnetic resonance imaging). INTs were classified by maximum diameter (<2, 2-20, and >20 mm), number, and location. The association between INT and clinical outcomes (modified Rankin Scale and death) was assessed using standard descriptive techniques and adjusted estimates of effect were derived from Poisson regression models.
Among 1092 patients, 103 had INT (9.3%, median age 69.5 years, 49.5% females). There were no differences in baseline characteristics between those with versus without INT. Most INTs (91/103, 88.3%) were not associated with visible occlusions on angiography and 39 out of 103 (37.8%) were >20 mm in maximal diameter. The most common INT territory was the anterior cerebral artery (27.8%). Almost half of the INTs were multiple (46 subjects, 43.5%, range, 2-12). INT was associated with poorer outcomes as compared to no INT on the primary outcome of modified Rankin Scale score of 0 to 2 at 90 days (adjusted risk ratio, 0.71 95% CI, 0.57-0.89). Infarct volume in those with INT was greater by a median of 21 cc compared with those without, and there was a greater risk of death as compared to patients with no INT (adjusted risk ratio, 2.15 95% CI, 1.48-3.13).
Infarcts in a new territory are common in individuals undergoing endovascular thrombectomy for acute ischemic stroke and are associated with poorer outcomes. Optimal therapeutic approaches, including technical strategies, to reduce INT represent a new target for incremental quality improvement of endovascular thrombectomy.
URL: https://www.
gov; Unique identifier: NCT02930018.
Governments and ethics boards increasingly require written informed consent from all subjects before enrollment in clinical registries. The authors of this article examine the effect of a ...comprehensive effort to obtain informed consent on the participation rate in the prospective Registry of the Canadian Stroke Network. The overall participation rate was 39.3 percent during phase 1 of the project and 50.6 percent during phase 2. Obtaining written consent was costly, leading to selection bias.
The effect of informed-consent requirements on the Canadian Stroke Network Registry.
Epidemiologic studies based on data from clinical registries have contributed to tremendous advances in modern medicine by enhancing our understanding of the natural history of disease and the value of many medical and surgical interventions. Studies using these data bases have increased the use of evidence-based medical therapies and have lowered the mortality rate associated with common conditions.
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Many clinical data bases have been developed without informed consent from patients. Researchers have argued that informed consent should not be required for participation in clinical data bases because there are large benefits to society from the research conducted and only . . .
For the clinician, the diagnosis of arterial ischemic stroke (AIS) in children is a challenge. Prompt diagnosis of pediatric AIS within 6 hours enables stroke-specific thrombolytic and ...neuroprotective strategies.
We conducted a retrospective study of prospectively enrolled consecutive cohort of children with AIS, admitted to The Hospital for Sick Children, Toronto, from January 1992 to December 2004. The data on clinical presentation, symptom onset, emergency department arrival, neuroimaging and stroke diagnosis were recorded. The putative predictors of delayed diagnosis were selected a priori for analysis.
A total of 209 children with AIS were studied. The median interval from symptom onset to AIS diagnosis was 22.7 hours (interquartile range: 7.1 to 57.7 hours), prehospital delay (symptom onset to hospital arrival) was 1.7 hours (interquartile range: 49 minutes to 8.1 hours), and the in-hospital delay (presentation to diagnosis) was 12.7 hours (interquartile range: 4.5 to 33.5 hours). The initial assessment was completed in 16 minutes and initial neuroimaging in 8.8 hours. The diagnosis of AIS was suspected on initial assessment in 79 (38%) children and the initial neuroimaging diagnosed AIS in 47%. The parent's help seeking action, nonabrupt onset of symptoms, altered consciousness, milder stroke severity, posterior circulation infarction and lack of initial neuroimaging at a tertiary hospital were predictive delayed AIS diagnosis.
In the diagnosis of AIS, significant prehospital and in-hospital delays exist in children. Several predictors of the delayed AIS diagnosis were identified in the present study. Efforts to target these predictors can reduce diagnostic delays and optimize the management of AIS in children.
Abstract Introduction Thrombocytopenia may be associated with a greater risk of cerebral hemorrhage and thrombocytosis may be associated with a greater risk of cerebral thrombosis. There is a paucity ...of studies focused on the potential association between blood platelet count (BPC) and outcomes after acute ischemic stroke (AIS). We hypothesized that abnormal BPC is associated with poorer outcomes after AIS. Methods This study included data from the Ontario Stroke Registry on consecutive patients with AIS admitted between July 2003 and March 2008. Patients were divided into groups as follows: low BPC (< 150,000/mm3 ), normal BPC (150,000 to 450,000/mm3 ) and high BPC (> 450,000/mm3 ). Primary outcome measures were the frequency of moderate/severe strokes on admission (Canadian Neurologic Scale: < 8), greater degree of disability at discharge (modified Rankin score: 3–6), and 30-day and 90-day mortality. Results We included 9230 patients. Both low and high BPC were associated with higher 30-day mortality (p ≤ 0.0335) and 90-day mortality (p ≤ 0.048) following AIS. The Kaplan–Meier curves indicate that abnormal BPC is associated with greater mortality after AIS (p = 0.0002). Nonetheless, abnormal BPC was not associated with initial stroke severity (p ≥ 0.225), degree of disability (p ≥ 0.3761), or length of stay in the acute stroke care center (p ≥ 0.7818) after adjustment for major potential confounders. Conclusions Thrombocytopenia and thrombocytosis on the initial admission are associated with higher mortality after AIS. Abnormal BPC does not adversely affect the degree of initial impairment, disability at discharge, or length of stay in the acute care hospital after AIS.
ObjectivesTo evaluate the association between immigration status and all-cause mortality in different disease cohorts, and the impact of loss to follow-up on the observed ...associations.DesignPopulation-based retrospective cohort study using linked administrative health data in Ontario, Canada.SettingWe followed adults with a first-ever diagnosis of ischaemic stroke, cancer or schizophrenia between 2002 and 2013 from index event to death, loss to follow-up, or end of follow-up in 2018.Primary and secondary outcome measuresOur outcomes of interest were all-cause mortality and loss to follow-up. For each disease cohort, we calculated adjusted HRs of death in immigrants compared with long-term residents, adjusting for demographic characteristics and comorbidities, with and without censoring for those who were lost to follow-up. We calculated the ratio of two the HRs and the respective CL using bootstrapping methods.ResultsImmigrants were more likely to be lost to follow-up than long-term residents in all disease cohorts. Not accounting for this loss to follow-up overestimated the magnitude of the association between immigration status and mortality in those with ischaemic stroke (HR of death before vs after accounting for censoring: 0.78 vs 0.83, ratio=0.95; 95% CL 0.93 to 0.97), cancer (0.74 vs 0.78, ratio=0.96; 0.95 to 0.96), and schizophrenia (0.54 vs 0.56, ratio=0.97; 0.96 to 0.98).ConclusionsImmigrants to Canada have a survival advantage that varies by the disease studied. The magnitude of this advantage is modestly overestimated by not accounting for the higher loss to follow-up in immigrants.
Considering that the incidence of dysphagia is as high as 55% following acute stroke, we undertook a systematic review of the literature to identify lesion sites that predict its presence after acute ...ischemic stroke.
We searched 14 databases, 17 journals, 3 conference proceedings and the grey literature using the Cochrane Stroke Group search strategy and terms for MRI and dysphagia. We evaluated study quality using the Cochrane Collaboration's risk of bias tool and extracted individual-level data. We calculated relative risks in order to model dysphagia according to neuroanatomical lesion sites.
Of 964 abstracts, 84 articles met the criteria for full review. Of these 84 articles, 17 met the quality criteria. These 17 articles dealt exclusively with dysphagia after infratentorial stroke and provided MRI correlates of dysphagia for 656 patients. The incidence of dysphagia according to stroke region was 0% in the cerebellum, 6% in the midbrain, 43% in the pons, 40% in the medial medulla and 57% in the lateral medulla. Within these regions, pontine (relative risk 3.7, 95% confidence interval 1.5-7.7), medial medullary (relative risk 6.9, 95% confidence interval 3.4-10.9) and lateral medullary lesions (relative risk 9.6, 95% confidence interval 5.9-12.8) predicted an increased risk of dysphagia.
We sought to develop a neuroanatomical model of dysphagia throughout the whole brain. However, the literature that met our quality criteria addressed the MRI correlates of dysphagia exclusively within the infratentorium. Although not surprising, these findings are a first step toward establishing a neuroanatomical model of dysphagia after infratentorial ischemic stroke and provide insight into the assessment of individuals at risk for dysphagia.
Systems of stroke care delivery have been promoted as a means of improving the quality of stroke care, but little is known about their effectiveness. We assessed the effect of the Ontario Stroke ...System, a province-wide strategy of regionalized stroke care delivery, on stroke care and outcomes in Ontario, Canada.
We used population-based provincial administrative databases to identify all emergency department visits and hospital admissions for acute stroke and transient ischemic attack from Jan. 1, 2001, to Dec. 31, 2010. Using piecewise regression analyses, we assessed the effect of the full implementation of the Ontario Stroke System in 2005 on the proportion of patients who received care at stroke centres, and on rates of discharge to long-term care facilities and 30-day mortality after stroke.
We included 243 287 visits by patients with acute stroke or transient ischemic attack. The full implementation of the Ontario Stroke System in 2005 was associated with an increase in rates of care at stroke centres (before implementation: 40.0%; after implementation: 46.5%), decreased rates of discharge to long-term care facilities (before implementation: 16.9%; after implementation: 14.8%) and decreased 30-day mortality for hemorrhagic (before implementation: 38.3%; after implementation: 34.4%) and ischemic stroke (before implementation: 16.3%; after implementation: 15.7%). The system's implementation was also associated with marked increases in the proportion of patients who received neuroimaging, thrombolytic therapy, care in a stroke unit and antithrombotic therapy.
The implementation of an organized system of stroke care delivery was associated with improved processes of care and outcomes after stroke.
Stroke and pregnancy JAIGOBIN, Cheryl; SILVER, Frank L
Stroke (1970),
12/2000, Letnik:
31, Številka:
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Journal Article
Recenzirano
Odprti dostop
We sought to characterize the subtypes of stroke associated with pregnancy and the puerperium, with emphasis on timing, etiology, risk factors, and outcome.
We conducted a retrospective analysis of ...patients admitted to the Toronto Hospital between January 1, 1980, and June 30, 1997, with a diagnosis of stroke during pregnancy or within 6 weeks postpartum. Strokes were classified as ischemic (arterial or venous) or hemorrhagic (subarachnoid or intracerebral). All patients were investigated with at least a CT scan of the head, and most had MRI and/or cerebral angiography.
Of approximately 50 700 admissions for delivery, 34 patients with a diagnosis of stroke were identified (21 infarctions and 13 hemorrhages). Of patients with infarction, 13 were arterial and 8 were venous. Nine of 13 arterial events occurred in the third trimester or puerperium. Seven of 8 venous occlusions occurred postpartum. An etiologic diagnosis was made in 7 of 13 patients with arterial territory infarction, including cardiac emboli, coagulopathies, and carotid artery dissection. Of patients with hemorrhage, 7 were subarachnoid and 6 were intracerebral. The etiology was identified in 10 patients: 3 were due to ruptured aneurysms, 5 were associated with arteriovenous malformations, and 2 were associated with disseminated intravascular coagulation. All patients with infarction survived, but 3 patients with hemorrhage died.
The majority of strokes associated with pregnancy were arterial occlusions. Most presented during the third trimester and puerperium.
The effect of endovascular therapy (EVT) for large vessel occlusion stroke on cognitive outcomes is not well understood. We evaluated the effect of EVT on cognitive function in the Endovascular ...Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial.
Patient data from the ESCAPE randomized trial were analyzed. Cognitive assessments completed at 90 days after stroke were the Montreal Cognitive Assessment (MoCA), the Sunnybrook Neglect Assessment Procedure (SNAP), the Boston Naming Test (BNT), Trail-making test A (Trails A), and Trail-making test B (Trails B). We used logistic regression to evaluate the association between EVT and favorable cognitive outcome on the 5 separate tests, adjusting for demographic and clinical factors. We used generalized estimating equations and ordinal regression to determine the odds of favorable outcome with EVT on global cognition incorporating the 5 tests. We added final infarct volume (FIV) to the models to assess the relationship of FIV with cognitive outcome.
The ESCAPE trial included 315 patients, 165 randomized to EVT and 150 randomized to control. There was higher odds of favorable outcome with EVT for MoCA (adjusted odds ratio aOR 2.32, 95% CI 1.30-4.16), SNAP (aOR 3.85, 95% CI 2.00-7.45), BNT (aOR 2.33, 95% CI 1.30-4.17), trails A (aOR 3.50, 95% CI 1.93-6.36), and trails B (aOR 2.56, 95% CI 1.46-4.48). There was higher odds of favorable outcome with EVT on global binary (aOR 2.57, 95% CI 1.67-3.94) and ordinal analyses (aOR 2.83, 95% CI 1.68-4.76) of cognitive function. After adding FIV to the models, both FIV and EVT were significantly associated with cognitive outcome. There was a significant correlation between global cognitive performance and mRS at day 90 (
= -0.78,
< 0.001), with the largest reductions in favorable cognitive outcome from mRS score 4 to 5 and from mRS 2 to 3.
In this secondary analysis of the ESCAPE trial, EVT was associated with favorable outcome on 5 separate cognitive tests and in global analyses of cognitive benefit. These results provide novel evidence for the effect of EVT on cognition and support the global benefit of treatment with EVT.
This study provides Class II evidence that in patients with acute ischemic stroke due to intracranial internal carotid artery (ICA) or M1 segment MCA occlusion, including tandem extracranial ICA occlusions, EVT compared with best medical therapy increased odds of favorable cognitive outcome.
BACKGROUND AND PURPOSE:The role of regional hypoperfusion as a contributor to stroke risk in atherosclerotic vertebrobasilar disease has recently been confirmed by the observational VERiTAS ...(Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke) Study. We examined the stability of hemodynamic status over time and its relationship to stroke risk in patients from this prospective cohort.
METHODS:VERiTAS enrolled patients with recently symptomatic ≥50% atherosclerotic stenosis/occlusion of vertebral and/or basilar arteries. Large vessel flow in the vertebrobasilar territory was assessed using quantitative magnetic resonance angiography, and patients were designated as low or normal flow based on distal territory regional flow, incorporating collateral capacity. Patients underwent standard medical management and follow-up for primary outcome event of vertebrobasilar territory stroke. Quantitative magnetic resonance angiography imaging was repeated at 6, 12, and 24 months. Flow status over time was examined relative to baseline and relative to subsequent stroke risk using a cause-specific proportional hazard model, with flow status treated as a time-varying covariate. Mean blood pressure was examined to assess for association with changes in flow status.
RESULTS:Over 19±8 months of follow-up, 132 follow-up quantitative magnetic resonance angiography studies were performed in 58 of the 72 enrolled patients. Of the 13 patients with serial imaging who had low flow at baseline, 7 (54%) had improvement to normal flow at the last follow-up. Of the 45 patients who had normal flow at baseline, 3 (7%) converted to low flow at the last follow-up. The mean blood pressure did not differ in patients with or without changes in flow status. The time-varying flow status remained a strong predictor of subsequent stroke (hazard ratio, 10.3 95% CI, 2.2–48.7).
CONCLUSIONS:There is potential both for improvement and worsening of hemodynamics in patients with atherosclerotic vertebrobasilar disease. Flow status, both at baseline and over time, is a risk factor for subsequent stroke, thus serving as an important prognostic marker.
REGISTRATION:URLhttps://clinicaltrials.gov. Unique identifierNCT00590980.
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