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.
ObjectiveBasilar artery occlusions, one of the most severe of large vessel occlusions, are associated with high mortality and morbidity even with appropriate intervention.Viz.AI, a novel technology ...facilitating rapid live consultation and imaging review with neurointerventional clinicians, holds promise in advising on optimal treatment or transport decisions. This study aims to assess whether implementing Viz.AI at a Comprehensive Stroke Center improved patient outcomes.Patients and MethodsWe identified 34 patients diagnosed with basilar artery occlusion who underwent thrombectomy at our Comprehensive Stroke Center from January 2018 to January of 2022. Electronic health records were reviewed to determine Viz.AI utilization in thrombectomy activation, as well as admit and discharge National Institutes of Health Stroke Scale (NIHSS) scores. We evaluated both admit and discharge NIHSS scores and changes in scores from admission to discharge.ResultsFor sixteen patients (47%) Viz.AI was utilized; these were compared to 18 (53%) in which Viz.AI was not used. Among the 18 patients where Viz.AI was not utilized, median admit NIHSS score was 21.5(IQR 9.3–30) and median discharge NIHSS was 17.5(IQR 4–22). The 16 patients who utilized Viz.AI had a median admit NIHSS score of 19(IQR 12–29) and a median discharge score of 1(IQR 1–4). In comparing groups, while no significant difference was found between admission NIHSS scores (p=0.96), a significant difference was found between discharge scores (p=0.006). Improvement in NIHSS score was significant highly in the Viz.AI group compared to the no-Viz.AI group. The no-Viz.AI group had a median change of 6.5(IQR 0–13) while the Viz.AI group had a median of 13(IQR 9–24); this represented a significant improvement in the Viz.AI group (p=0.04).ConclusionFollowing the implementation of Viz.AI at a Comprehensive Stroke Center, patients who entered with comparable deficits as measured by NIHSS scores had a significant improvement in discharge scores and change in score from admission. While multifactorial, this observation highlights the potential of Viz.AI in enhancing neurological outcomes in cases of basilar occlusions. Further investigation into surrounding factors is warranted to elucidate its full impact.Abstract E-049 Figure 1DisclosuresD. Williams-Stankewicz: None. E. Paulin: None. J. Frank: None. J. Lee: None. M. Campbell: None. L. Wise: None. D. Lukins: None. M. Al-Kawaz: None. D. Dornbos: None. S. Pahwa: None. J. Fraser: None.
Background and PurposeHealthcare systems in the United States are increasingly transitioning from alteplase (TPA) to tenecteplase (TNK) as primary thrombolytic in acute ischemic stroke care. We ...explore the safety and effectiveness of replacing TPA with TNK before large vessel occlusion (LVO) stroke endovascular treatment (EVT).MethodsRetrospective multicenter cohort study of LVO stroke patients who received intravenous thrombolysis with TPA or TNK before EVT across healthcare systems in Pennsylvania between 01/2020 - 06/2023. All stroke systems transitioned to TNK during the study period. Multivariate logistic analysis was conducted with pre-specified adjustments for age, sex, National Institute of Health Stroke Scale (NIHSS), occlusion site, last-known-well (LKW) to intravenous thrombolysis time (IVT), interhospital-transfer and stroke-system. Of 851 identified patients, 635 met prespecified analysis criteria (proximal LVO, pre-stroke modified Rankin Scale (mRS) < 3, LKW-to-IVT ≤ 4.5 hours).ResultsOf 635 patients, 309 (48.7%) received TNK and 326 (51.3%) TPA prior to EVT. The site of occlusion was the M1 (MCA) (47.7%), M2 MCA (25.4%), ICA (14.0%), tandem carotid with M1 or M2 MCA (9.8%) and BA (3.1%). TNK and TPA patients had similar age, sex, NIHSS, occlusion sites, Alberta Stroke Program Early CT Score (ASPECT), and LWK-to-IVT. A favorable functional outcome (90-day mRS < 3) was observed in 47.6% of TNK and 49.7% of TPA patients (aOR 0.72 (95% CI 0.47 - 1.10), p=0.132). TNK versus TPA groups had similar rates of successful endovascular reperfusion (93.5% vs. 89.3%, aOR 1.19 (0.58 - 2.43), p=0.627), symptomatic intracranial hemorrhage (3.2% vs. 3.4%, aOR 0.54 (0.20 - 1.44, p=0.218) and 90-day all-cause mortality (23.1% vs. 21.5%, aOR 1.21 (0.71 - 2.06, p=0.491).ConclusionsIn this U.S. real-world multicenter experience, TNK compared to TPA before LVO stroke EVT had similar safety and effectiveness profiles.DisclosuresP. Hendrix: None. B. Gross: None. S. Allahdadian: None. G. Sioutas: None. P. Koul: None. A. Tarbay: None. M. Lang: None. V. Srinivasan: None. A. Al-Bayati: None. J. Li: None. A. Noto: None. R. Nogueira: None. J. Burkhardt: None. R. Zand: None. C. Schirmer: None.
BackgroundThe ANA Mechanical Thrombectomy (MT) device (Anaconda Biomed, Barcelona) comprised of a self-expanding coated funnel, works in conjunction with a standard stentretriever, and is designed to ...locally restrict flow and reduce clot fragmentation. The ANAIS Study investigated the performance of the ANA device and which procedural circumstances improve its efficacy.MethodsProspective, single-arm, multi-center study with blinded outcomes assessment by independent imaging core lab. Patients with anterior circulation stroke undergoing MT were eligible. Primary endpoint was successful reperfusion (eTICI≥2b) within three passes without rescue therapy. Safety endpoint combined symptomatic Intracranial Hemorrhage (sICH) and adverse severe device effects (SADE).Results43 subjects were treated in 3 centers: mean age: 70.5±13.1 years, median admission National Institutes of Health Stroke Scale 16.0 12.5–19.5. Primary endpoint was achieved in 70% (30/43) and 81% (26/32) in the intention to treat (ITT) and per protocol (PP) populations, respectively. The rate of first pass eTICI2c-3 was 44% (19/43) and 56% (18/32) in the ITT and PP populations, respectively. There were no SADE/sICH at 24h (0/43). When the funnel was deployed in C1 segment of the internal carotid artery (ICA) the primary endpoint (ITT: 36%; PP: 57%) was lower than when deployed in the C2/C3 segments (ITT:89%; PP:100%; p < 0.02), or in the C4 segment of higher (ITT:71%; PP:77%; p < 0.01). Primary endpoint was higher when continuous aspiration was applied from initiation of retrieval maneuver (ITT:81%; TT:92%) as compared to end aspiration only (ITT36%/50%, ITT and PP populations, p < 0.01). In the mITT population (n=25) which included patients in which the funnel was deployed in the optimal segment (C2/3) and aspiration was continuously applied the primary endpoint was achieved in 96% and the rate of first pass eTICI2c-3 was 61.3%.ConclusionsThe ANA device achieved high rates of recanalization and first pass success, with a good safety profile. Successful reperfusion was superior when the funnel was deployed above the C1 segment of ICA and clot retrieval performed under continuous aspiration.DisclosuresM. Ribo: None. J. Zamarro: None. M. Terceño: None. S. Bashir: None. L. Gramegna: None. M. Requena: None. F. Diana: None. E. Rivera: None. M. De Dios: None. D. Hernandez: None. S. Snchez: None. I. Galve: 5; C; R&D. A. Tomasello: None.
IntroductionThe impact of timeliness of revascularization on outcomes for patients presenting with acute LVO stroke is undeniable. The Delaware Stroke System (DSS) is comprised of 6 PSCs throughout ...the state, and a single CSC (also the closest CSC/TSC to all DE hospitals). Ground transport times to the CSC can reach up to 85 minutes for the furthest PSC when unable to fly. In conjunction with state average door-in-door-out times that approach nearly 2 hours, this can result in significant delays to revascularization for the most critically ill LVO stroke patients. Historically, only 52% of LVO patients transferred to the CSC underwent thrombectomy (FY22), with the most common reason for no thrombectomy being completed infarct on arrival to the CSC due to prolonged transport times.MethodsThe DSS, comprised of representatives from all DE hospitals, DPH, and EMS, came together to improve the in-field evaluation and routing of stroke patients with possible LVO to optimize timeliness of revascularization therapy. In Spring 2022, the DSS decided upon the VAN score for EMS in-field evaluation for LVO (changed from RACE score due to suboptimal completion rates in the field). The DSS concurrently worked with the state EMS Medical Director to implement changes to the EMS Standing Order with respect to in-field evaluation and routing, allowing EMS to bypass the closest PSC in lieu of direct transport to the CSC for suspected LVO patients when able to fly (after contacting local ED physician/med control). These changes were approved by the DE Board of Medical Licensure and Discipline during Summer 2022. EMS education was completed in October 2022, including direct education to every prehospital paramedic by the state EMS Medical Director. The process went live in November 2022. Data was collected and analyzed to assess the volume of direct transfers from the field to the CSC, as well as their diagnosis and thrombectomy rates.ResultsDuring the first full year of implementation (CY23), a total of 100 patients were flown directly from the field throughout DE to the CSC, bypassing the local PSC. Of these patients, 57% had a final diagnosis of stroke (AIS/ICH/SAH). 44% had AIS, and 17% received IV thrombolytics (39% of AIS patients). 29% had LVO (66% of patients with final diagnosis of AIS) and 23/29 (79%) underwent thrombectomy.ConclusionBy implementing an evidence-based LVO screening tool for EMS use in the field and routing for suspected LVO patients directly to a CSC by air, bypassing the local PSC, the DSS was able to improve the likelihood of thrombectomy for LVO patients throughout the state to 79% compared to a historical baseline of 52% when those patients arrived as interfacility transfers. These patients also received thrombectomy an estimated 2–3 hours earlier than if they had presented to the local PSC first. We are working to improve the utilization of the field screening tool to minimize unnecessary transfers, keep more patients at their local PSC when appropriate, while still optimizing delivery of mechanical thrombectomy to LVO patients throughout our state.DisclosuresT. Sivapatham: None. M. Ciechanowski: None. R. Rosenbaum: None. M. Dworkin: None. S. Kappers: None.
BackgroundAcute ischemic stroke (AIS) due to distal medium vessel occlusions (DMVO) presents significant challenges in treatment and management. This study aimed to identify factors associated with ...achieving excellent recanalization (mTICI 2c-3) in DMVO stroke patients treated with mechanical thrombectomy (MT).MethodsThis prospectively collected, retrospective reviewed multinational, multicenter study analyzed the Multicenter Analysis of primary Distal medium vessel occlusions: effect of MechanicalThrombectomy (MAD-MT) registry. We included data from 37 centers across North America,Asia, and Europe, collected between September 2017 and July 2021. The study included AIS patients with DMVO treated with MT, with or without intravenous thrombolysis (IVT), and recorded mTICI scores post-MT. Univariable and multivariable logistic regression models assessed factors associated with excellent recanalization.ResultsAmong 1,463 patients with DMVO stroke, 523 achieved TICI 2b recanalization, and 940 achieved TICI 2c-3. Our analysis revealed that distal occlusions had higher odds of excellent recanalization compared to medium vessel occlusions (OR, 1.50; 95% CI, 1.11–2.05; p=0.01).Cardioembolic stroke etiology was also associated with a higher likelihood of excellent recanalization (OR, 1.70; 95% CI, 1.09–2.66; p=0.019). Patients achieving TICI 2c-3 recanalization exhibited lower initial NIHSS scores, significant improvements post-procedural NIHSS shift, and higher percentage of favorable 90-day outcomes. However, no significantdifference in 90-day mortality rates was observed.ConclusionThis study underscores the higher likelihood of achieving excellent recanalization in DMVO stroke patients with distal occlusions and cardioembolic etiology. Patients attaining higher mTICI scores post-MT demonstrated better clinical outcomes. These findings highlight thepotential for broader applicability of MT in DMVO cases and suggest a need for furtherprospective studies and randomized controlled trials for validation.DisclosuresB. Musmar: None. N. Adeeb: None. H. Salim: None. S. Ghozy: None. N. M Cancelliere: None. V. Mendes Pereira: None. A. Guenego: None. P. Jabbour: None. A. A Dmytriw: None. V. Yedavalli: None.
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