Ischemic Stroke Feske, Steven K.
The American journal of medicine,
December 2021, 2021-12-00, 20211201, Letnik:
134, Številka:
12
Journal Article
Recenzirano
This concise review of the epidemiology, pathophysiology, evaluation, acute management, and prevention of ischemic stroke targets internists, family practitioners, and emergency physicians who manage ...patient with stroke.
This publication describes uniform definitions for cardiovascular and stroke outcomes developed by the Standardized Data Collection for Cardiovascular Trials Initiative and the U.S. Food and Drug ...Administration (FDA). The FDA established the Standardized Data Collection for Cardiovascular Trials Initiative in 2009 to simplify the design and conduct of clinical trials intended to support marketing applications. The writing committee recognizes that these definitions may be used in other types of clinical trials and clinical care processes where appropriate. Use of these definitions at the FDA has enhanced the ability to aggregate data within and across medical product development programs, conduct meta-analyses to evaluate cardiovascular safety, integrate data from multiple trials, and compare effectiveness of drugs and devices. Further study is needed to determine whether prospective data collection using these common definitions improves the design, conduct, and interpretability of the results of clinical trials.
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People with type 2 diabetes (T2D) are at elevated risk of cardiovascular disease (CVD) including stroke, yet existing real-world evidence (RWE) on the clinical and economic burden of stroke in this ...population is limited. The aim of this cohort study was to evaluate the clinical and economic burden of stroke among people with T2D in France.
We conducted a retrospective RWE study using data from the nationally representative subset of the French Système National des Données de Santé (SNDS) database. We assessed the incidence of stroke requiring hospitalization between 2012 and 2018 among T2D patients. Subsequent clinical outcomes including CVD, stroke recurrence, and mortality were estimated overall and according to stroke subtype (ischemic versus hemorrhagic). We also examined the treatment patterns for glucose-lowering agents and CVD agents, health care resource utilization and medical costs.
Among 45,331 people with T2D without baseline history of stroke, 2090 (4.6%) had an incident stroke requiring hospitalization. The incidence of ischemic stroke per 1000 person-years was 4.9-times higher than hemorrhagic stroke (6.80 95% confidence interval (CI) 6.47-7.15 versus 1.38 1.24-1.54). During a median follow-up of 2.4 years (interquartile range 0.6; 4.4) from date of index stroke, the rate of CVD, stroke recurrence and mortality per 1000 person-years was higher among hemorrhagic stroke patients than ischemic stroke patients (CVD 130.9 107.7-159.0 versus 126.4 117.2-136.4; stroke recurrence: 86.7 66.4-113.4 versus 66.5 59.2-74.6; mortality 291.5 259.1-327.9 versus 144.1 134.3-154.6). These differences were not statistically significant, except for mortality (adjusted hazard ratio 1.95 95% CI 1.66-2.92). The proportion of patients prescribed glucagon-like peptide-1 receptor agonists increased from 4.2% at baseline to 6.6% during follow-up. The proportion of patients prescribed antihypertensives and statins only increased slightly following incident stroke (antihypertensives: 70.9% pre-stroke versus 76.7% post-stroke; statins: 24.1% pre-stroke versus 30.0% post-stroke). Overall, 68.8% of patients had a subsequent hospitalization. Median total medical costs were €12,199 (6846; 22,378).
The high burden of stroke among people with T2D, along with the low proportion of patients receiving recommended treatments as per clinical guidelines, necessitates a strengthened and multidisciplinary approach to the CVD prevention and management in people with T2D.
One of the most important causes of neurological morbidity and mortality in the world is ischemic stroke. It can be a result of multiple events such as embolism with a cardiac origin, occlusion of ...small vessels in the brain, and atherosclerosis affecting the cerebral circulation. Increasing evidence shows the intricate function played by the immune system in the pathophysiological variations that take place after cerebral ischemic injury. Following the ischemic cerebral harm, we can observe consequent neuroinflammation that causes additional damage provoking the death of the cells; on the other hand, it also plays a beneficial role in stimulating remedial action. Immune mediators are the origin of signals with a proinflammatory position that can boost the cells in the brain and promote the penetration of numerous inflammatory cytotypes (various subtypes of T cells, monocytes/macrophages, neutrophils, and different inflammatory cells) within the area affected by ischemia; this process is responsible for further ischemic damage of the brain. This inflammatory process seems to involve both the cerebral tissue and the whole organism in cardioembolic stroke, the stroke subtype that is associated with more severe brain damage and a consequent worse outcome (more disability, higher mortality). In this review, the authors want to present an overview of the present learning of the mechanisms of inflammation that takes place in the cerebral tissue and the role of the immune system involved in ischemic stroke, focusing on cardioembolic stroke and its potential treatment strategies.
Endovascular therapy for stroke is generally avoided if the cerebral infarction is large. In a trial conducted in Japan, the percentage of patients who had a good functional outcome at 90 days was ...higher with endovascular therapy than with medical care, but there were more cerebral hemorrhages with endovascular therapy.
Current stroke guidelines do not facilitate the expedient diagnosis of inflammatory stroke. At UCLH, we have integrated intracranial vessel wall imaging (iVWI) into our stroke pathway to overcome ...this barrier. We present a case, where iVWI facilitated the diagnosis and helped us interpret a further asymptomatic stroke event.A 36-year-old man presented with left sided facial weakness. He had type 2 diabetes, hypertension, obesity, and hypercholesterolaemia. CT showed a right MCA/ACA infarct with severe bilateral ICA stenosis. MRI confirmed a borderzone infarct. The patient was treated with anti-platelets, a statin and continued ramipril and amlodipine. iVWI imaging identified an unexpected inflammatory vasculopathy. His CSF was supportive of CNS inflammation, and thus, commenced on prednisolone and empirical valaciclovir. His 3-month interval scan showed new asymptomatic borderzone infarcts that were concordant with hypoperfusion injury, and temporally linked with the initiation of indapamide by his GP, this was subsequently stopped. His vasculopathy remained static. A six-month interval scan showed no new lesion, and improvement of his inflammatory vasculopathy. Using iVWI, we were able to diagnose an inflammatory vasculopathy that could have been missed. The case also highlighted that excessive early reduction of blood pressure can contribute to hypoperfusion related stroke.
We provided Alexa devices-Amazon Echo Show and Echo Spot to a 56- year old patient recovering from an ischaemic stroke at home. Amazon Echo device is a WiFi connected device driven by Alexa, a voice ...assistant. We trained our patient on the use and control of the devices using her voice and provided technical know how. Once set up, she was able to use the voice control to perform several tasks-listening to news listening to music and radioplaying sounds for meditationturning on and off lightssetting up alarms for medicationssetting up times for doing scheduled exercisemaking hands free phone callsThis was especially useful when her carer was not present by her side. Later on we added Amazon cloud cam to the set up so that family members could remotely monitor her activity.She was able to make the physiotherapy sessions fun and interesting with the help of apps running on the devices upon voice prompts.In the emerging economies the joint family structure is breaking down. The relatives working as informal carers are disappearing fast. The main care is often provided by the privately hired nurses or health care assistants provided by local agencies. The cost of such private care is high. In this background, the voice activated cloud devices could play a significant role in the rehabilitation following a stroke.
IntroductionFor large vessel occlusions, 24h NIHSS was described as most accurate early clinical predictor of functional outcome in acute stroke patients. M2 occlusions are characterized by more ...distal and smaller infarct cores, early clinical surrogates of functional outcome might differ.Aim of StudyTo investigate early clinical surrogates for long-term independency of patients treated with mechanical thrombectomy for M2 occlusion stroke in comparison to patients with M1 occlusion stroke.MethodsAll patients enrolled in the German Stroke Registry-Endovascular Treatment (05/2015–12/2021; N=13082) were screened for anterior circulation stroke. Receiver-operating-characteristics(ROC)-curve analyses and area-under-the-curve(AUC) were used to evaluate the performance of admission NIHSS, 24h NIHSS and NIHSS percentage and absolute change to predict functional outcome at 90d. Excellent and good outcome were defined as modified Rankin Scale(mRS) 0–1 and 0–2, respectively.Results1268 patients with M2 and 2749 patients with M1 occlusion were included. For both cohorts, 24h NIHSS had the highest discriminative ability to predict excellent functional outcome with AUC=0.86(95%CI=0.84–0.88) for M2 and AUC=0.86(0.84–0.88) for M1 occlusions. Optimal cutoffs were NIHSS≤7 and NIHSS≤8, respectively. Good long-term functional outcome was predicted with AUC=0.86(0.85–0.88) for M2 and AUC=0.86(0.85–0.88) for M1 occlusions with optimal cut-offs NIHSS≤8 and NIHSS≤9, respectively.Conclusion24h NIHSS was identified as best surrogate for long-term functional outcome after thrombectomy for patients with M1 and M2 occlusion, while optimal cut-offs to predict good and excellent outcome were 1 NIHSS-point higher in M2 occlusions compared to M1 occlusions.Disclosure of InterestHK has financial interest in Eppdata GmbH.GT received fees as consultant and lecturer from Acandis, Alexion, Amarin, Boehringer Ingelheim, Bayer, BMS/Pfizer, Daiichii Sankyo and Portola. He serves in the board of the TEA Stroke Study and of ESO.JF is consultant for Cerenovus, Medtronic, Microvention, Penumbra, Phenox, Roche, Stryker and Tonbridge. He is stock holder of Tegus Medical, Eppdata and Vastrax. He serves as Associate Editor at JNIS.All other authors have nothing to disclose.
IntroductionFirst-pass(FP)-recanalization has been shown to improve outcome in patients with ischemic stroke undergoing mechanical thrombectomy(MT). Data also suggests that FP-recanalization is more ...often associated with complete reperfusion TICI=3 than with TICI=2b. Independently, it was shown that TICI=3 significantly improves functional outcome after mechanical thrombectomyAim of StudyTo evaluate whether early recanalization or complete recanalization TICI=3 are the determinants of improved outcome observed after FP-recanalization.MethodsAll patients prospectively enrolled in the German Stroke Registry-ET (05/2015–12/2021;N=13082) were screened. Inclusion criteria were anterior circulation stroke and successful recanalization TICI≥2b. Good functional outcome was defined as 90d modified Rankin Scale(mRS)≤2. Mediation analysis was performed to evaluate how much of the FP-related improvement in functional outcome is explained by complete reperfusion TICI=3.Results2589 patients were included, 1170(47%) had successful FP recanalization, 797(68% of FP-cases) with TICI=3. FP-recanalization was associated with higher rate of good functional outcome compared to multi-pass with 49.2% vs 37.6%. Mediation analysis suggests that FP-recanalization increases probability of good outcome by 9.6 percentage points vs. multi-pass recanalization. 12.8% (95%CI:7.6%-23%) of this effect was explained by TICI=3 recanalization whereas 87.2% (77%-92%) are explained by other factors associated with FP- recanalization.ConclusionOnly 13% of the FP-related improvement in functional outcome is explained by higher rates of complete recanalization, suggesting significant importance of early recanalization and low number of MT maneuvers. Results may improve the understanding of the importance of FP-reperfusion vs. early TICI=3 and may help to optimize MT treatment strategies.Disclosure of InterestHK has financial interest in Eppdata GmbH.GT received fees as consultant and lecturer from Acandis, Alexion, Amarin, Boehringer Ingelheim, Bayer, BMS/Pfizer, Daiichii Sankyo and Portola. He serves in the board of the TEA Stroke Study and of ESO.JF is consultant for Cerenovus, Medtronic, Microvention, Penumbra, Phenox, Roche, Stryker and Tonbridge. He is stock holder of Tegus Medical, Eppdata and Vastrax. He serves as Associate Editor at JNIS.All other authors have nothing to disclose.
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