Background and Aims: Cryptogenic ischemic strokes (CIS) are treated with antiplatelets for stroke prevention in routine clinical practice. The objective of this study was to investigate whether the ...CHADS2 and CHA2DS2-VASc scores may be used to identify the patients with CIS at higher risk of ischemic stroke despite antiplatelet therapy.
Material and Methods: We calculated CHADS2 and CHA2DS2-VASc scores in patients with first ever CIS; those previously managed with antiplatelets (AP group) and in those without antiplatelets (non-AP group), using the prospectively recorded data of the Istanbul Medical School Stroke Registry from 1996-2014.
Results: Of the 4466 IS patients, 886 patients with first ever IS had complete data for score calculation. Seventy-five (39 women) of them were diagnosed with CIS. CHADS2 and CHA2DS2-VASc scores were significantly higher in the AP group of 19 patients in comparison to the non-AP group of 56 patients (P = 0.005 and P = 0.009, respectively). ROC curve analyses showed an area under curve (AUC) of 0.705 (CI: 0.57-0.84; P = 0.008) for CHADS2 score ≥3 and AUC of 0.699 (CI: 0.57-0.82; P = 0.01) for CHA2DS2-VASc score ≥4. Vascular diseases were more frequent in the AP group and these patients were older than the patients in the non-AP group (P = 0.025, P = 0.024; respectively).
Conclusions: CHA2DS2-VASc score ≥ 4 and CHADS2 score ≥3 may be used as a predictor of the occurrence of IS despite regular antiplatelet use and suggest an embolic source which will respond better to anticogulation. Our results support that CHADS2 and CHA2DS2-VASc scores may be useful to identify subgroups among patients with CIS for individualizing diagnostic approach, planning future workup and preventive treatment.
081 Description of a stroke unit mimic admissions Cashion, Catelyn; Gawarikar, Yash; Patel, Ronak
Journal of neurology, neurosurgery and psychiatry,
06/2018, Letnik:
89, Številka:
6
Journal Article
Recenzirano
IntroductionThere is evidence to support both clinically and economically that stroke units improve stroke outcomes, but this is offset by high stroke mimics rates, which account for up to quarter of ...stroke unit admissions. There is no Australian data looking at stroke mimic rates and the time of day when they are admitted.MethodsWe conducted a retrospective cross-sectional study at Calvary Public Hospital, Bruce from May 2014 to May 2017 looking at stroke unit admission rates and mimic types. We collected data on the times of stroke unit admission, business hours Monday to Friday 0800–1630 hours and after-hours Monday to Friday 1630–0800 hours, weekends 0800–0800 hours. Stroke mimics length of stay (LOS) was compared with TIA mild strokes (NIHSS <5) LOS.ResultsOut of 1017 stoke unit admissions, 257 (25.3%) were stroke mimics. The most common mimic diagnoses were migraine and headaches (18.3%), peripheral vestibulopathy (14.0%), and functional neurology (13.2%). Data on admission times were available for 240 of 257 (93.4%) mimics of which more than 2/3 s of mimics were admitted after-hours; Bayes factor 0.912 demonstrating this is unlikely to be a significant difference. 3.5% of stroke mimics were thrombolysed with 2/3 s occurring after-hours. The average LOS was 2.3 days for mimics, compared to 4.0 days for TIA and minor strokes (p=0.00017).ConclusionOur study shows similar stroke mimic rates as previously described in literature with a higher proportion of these patients were admitted after-hours. However, there is little evidence that this difference is significant. The LOS for stroke mimics was less than TIAs and minor strokes. Our study highlights the need for better recognition of stroke mimics in order to prevent unnecessary utilisation of a valuable resource such as the stroke unit.
In a trial involving patients with large acute strokes, endovascular thrombectomy resulted in better functional outcomes than medical care alone but was associated with vascular complications.
Abstract
Introduction
Among several physiologic factors to influence the occurrence of ischemic stroke, the serum concentration of plasminogen activator inhibitor-1 was shown to have clear circadian ...variation, which could influence platelet aggregation, blood viscosity, and endogenous/exogenous fibrinolytic activity. The aim of our study is to investigate whether the efficacy of intravenous recombinant tissue plasaminogen activator (r-tPA) could have circadian variation in patients with acute ischemic stroke and in the stroke subtypes according to etiologic mechanisms.
Methods
Retrospectively, 1,923 patients treated with IV r-tPA for acute ischemic stroke were identified from the Clinical Research Center for Stroke (CRCS) 5th division registry database in Korea. The patients were categorized by stroke onset time by every 4 hours (23-3h, 3-7h, 7-11h, 11-15h, 15-19h, and 19-23h). Stroke onset time was defined by last normal time. Demographic information and National Institute of Health stroke scales (NIHSS) were analyzed. For IV t-PA efficacy analysis, NIHSS at the emergency room (iNIHSS), NIHSS at 24 hours after IV r-tPA administration (day#1NIHSS), and a change of follow-up NIHSS (subtraction of day#1NIHSS from iNIHSS: cNIHSS) were used. Three stroke subgroups according to TOAST classification (large artery atherosclerosis, LAA; small vessel occlusion, SVO; cardio-embolism, CE) were separately reviewed.
Results
The whole group analysis showed no statistically significant difference of NIHSS improvement according to the time of day of stroke onset although 23-3h group had the highest cNIHSS and followed by 3-7h group. LAA, CE group showed the same pattern as the whole group. cNIHSS of the 3-7h group was higher than that of 23-3h and other time of the day in patients with SVO group without statistical significance.
Conclusion
Our study did not show a definite circadian variation of the efficacy of iv t-PA measured by NIHSS change at 24h after administration. Further subgroup analysis depending on the severity of initial neurologic dysfunction and a long-term outcome will be needed.
Support (If Any)
N/A.
Abstract
Introduction
Stroke alters cortical disinhibition/excitability affecting motor control presumably increasing LMS. This study evaluates all LMS with durations accepted for PLMS (0.1 to 10s) ...for affected and unaffected side of early-phase stroke patients compared to matched controls
Methods
LMS from leg activity meters were obtained on 11 patients 3–19 days post stroke and 10 age and gender-matched controls. Average NIH stroke severity scale was 9.7 ± 4(range 4–18). Records were scored using revised PLM criteria that end a run of LMS whenever the inter-movement interval between onsets (IMI) is too short. This avoids erroneously accepting many closely spaced LMS with too short IMI as classical PLMS.
Results
The number and the standard deviation of durations of LMS with short IMI (<10 seconds) for stroke patients were larger but PLMS/hr with IMI >10, < 90 seconds did not differ compared to control. The difference between unaffected and affected sides in LMS/hr with IMI<10 s was high in cortical and subcortical stroke and minimal in brainstem stroke
Conclusion
LMS observed post-stroke are not typical PLMS in their characteristics nor is the density of PLMS significantly greater than normal healthy adults. Numbers of LMS packed closely together (onsets<10 s apart) are both excessive and more on the unaffected than affected side for cortical and subcortical but not brainstem stroke. These assessments of LMS with short intervals between onsets may provide objective motor output measures of disinhibition/excitability reflecting neural plasticity relevant for post-stroke recovery.
Support (If Any)
Gift account.
IMPORTANCE: In nonurban areas with limited access to thrombectomy-capable centers, optimal prehospital transport strategies in patients with suspected large-vessel occlusion stroke are unknown. ...OBJECTIVE: To determine whether, in nonurban areas, direct transport to a thrombectomy-capable center is beneficial compared with transport to the closest local stroke center. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, population-based, cluster-randomized trial including 1401 patients with suspected acute large-vessel occlusion stroke attended by emergency medical services in areas where the closest local stroke center was not capable of performing thrombectomy in Catalonia, Spain, between March 2017 and June 2020. The date of final follow-up was September 2020. INTERVENTIONS: Transportation to a thrombectomy-capable center (n = 688) or the closest local stroke center (n = 713). MAIN OUTCOMES AND MEASURES: The primary outcome was disability at 90 days based on the modified Rankin Scale (mRS; scores range from 0 no symptoms to 6 death) in the target population of patients with ischemic stroke. There were 11 secondary outcomes, including rate of intravenous tissue plasminogen activator administration and thrombectomy in the target population and 90-day mortality in the safety population of all randomized patients. RESULTS: Enrollment was halted for futility following a second interim analysis. The 1401 enrolled patients were included in the safety analysis, of whom 1369 (98%) consented to participate and were included in the as-randomized analysis (56% men; median age, 75 IQR, 65-83 years; median National Institutes of Health Stroke Scale score, 17 IQR, 11-21); 949 (69%) comprised the target ischemic stroke population included in the primary analysis. For the primary outcome in the target population, median mRS score was 3 (IQR, 2-5) vs 3 (IQR, 2-5) (adjusted common odds ratio OR, 1.03; 95% CI, 0.82-1.29). Of 11 reported secondary outcomes, 8 showed no significant difference. Compared with patients first transported to local stroke centers, patients directly transported to thrombectomy-capable centers had significantly lower odds of receiving intravenous tissue plasminogen activator (in the target population, 229/482 47.5% vs 282/467 60.4%; OR, 0.59; 95% CI, 0.45-0.76) and significantly higher odds of receiving thrombectomy (in the target population, 235/482 48.8% vs 184/467 39.4%; OR, 1.46; 95% CI, 1.13-1.89). Mortality at 90 days in the safety population was not significantly different between groups (188/688 27.3% vs 194/713 27.2%; adjusted hazard ratio, 0.97; 95% CI, 0.79-1.18). CONCLUSIONS AND RELEVANCE: In nonurban areas in Catalonia, Spain, there was no significant difference in 90-day neurological outcomes between transportation to a local stroke center vs a thrombectomy-capable referral center in patients with suspected large-vessel occlusion stroke. These findings require replication in other settings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02795962
Background The efficacy of device closure for patent foramen ovale (PFO) for crypotenic stroke has been controversial. PFO closure was superior to medical therapy for prevention of stroke (HR 0.31, ...95% confidence interval (CI) 0.12 to 0.79, p=0.015, heterogeneity I2 = 69.8%).
Abstract only Introduction Patients with baseline disability account for one‐third of stroke presentations. However, there remains controversy in treatment selection for endovascular thrombectomy ...(EVT). We compared long‐term outcomes and likelihood of transitioning to comfort care for large vessel occlusion (LVO) patients with severe pre‐stroke disability treated with EVT versus medical management at a single center from 2017‐2020. Methods Individuals who presented with LVO were identified retrospectively from a prospectively maintained database. Severe baseline disability was defined as modified Rankin Scale (mRS) 3‐5. Delta mRS was defined as the difference between baseline and 90‐day mRS. Logistic and ordinal regressions were performed to evaluate the relationships between EVT and outcomes. A mixed‐methods analysis was performed to assess rates and reasons for transitions to comfort care. Results A total of 175/1008 (17%) were identified with severe baseline disability. The median age was 82 (IQR 70‐89), and 59% were female. Thirty‐two (18%) with severe baseline disability were treated with EVT. EVT was independently associated with improved delta mRS (B=‐1.048; 95%CI=‐1.777,‐0.318; p=0.005) accounting for age and NIHSS. However, EVT did not reduce the odds of transitioning to comfort care (aOR=0.794; 95%CI=0.347,1.818; p=0.585) accounting for age and NIHSS. Seventy‐six (43%) with severe baseline disability were transitioned to comfort care. Of the 99 not transitioned to comfort care, 18 were treated with EVT, and EVT was independently associated with improved delta mRS (B=‐2.794; 95%CI=‐4.002,‐1.586; p<0.0001) accounting for age and NIHSS. The median time from presentation to comfort care was 2 days (IQR 1‐7) in the non‐EVT group, compared to 7 (IQR 4‐11) in the EVT group (H(1)=5.46, p=0.019). The primary reasons for comfort care were poor perceived prognosis and medical complications. Conclusion Among patients with severe baseline disability, EVT is associated with less post‐stroke accumulated disability without limiting transitions to comfort care. EVT may be compatible with goal‐concordant care and should not be routinely withheld on the basis of baseline disability alone.
Abstract only Introduction Mechanical thrombectomy (MT) is the standard of care for patients with large vessel occlusion and salvageable tissue. Whether the benefit of thrombectomy is maintained for ...patients transferred to a thrombectomy‐capable center in a real‐world setting remains unknown. In this study, we sought to assess clinical outcomes of MT following inter‐hospital transfer. Methods We collected data for all patients who underwent MT at a single center between May 2016 and July 2021. Outcomes were compared between transferred and direct admit patients. Our outcomes measurements included National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 90 days. We used Mann‐Whitney U and chi‐square tests for univariate analysis. Multivariate regression analysis was also carried out to assess the relationship between transfer status and long‐term functional independence (90 days mRS 0‐2) controlling for age, sex, symptom‐onset to groin time, IV thrombolysis, and baseline NIHSS. Results 246/620 (40%) patients undergoing MT were transferred and 374/620 (60%) presented directly to our institution. There was no difference in age (68 vs. 70 years, P=0.58), baseline NIHSS (16 vs. 15, P=0.20), or ASPECTs score (7 vs. 8, P=0.06) in the transferred and direct admit groups, respectively. The duration from symptom‐onset to groin was longer (393 vs. 270 min, P<0.01) and rate of IV thrombolysis was more (48.4% vs. 37.4%, P=0.007) in the transferred patients. Functional independence (mRS 0‐2) at 90 days was observed in 44.6% of the patients in the transferred group compared to 49.2% in the direct thrombectomy group (P=0.928). On multivariate analysis, transfer status was not an independent predictor of long‐term functional independence (ARR 1.976, 95% CI 0.807‐4.838, P=0.136). Conclusion In the included cohort, no difference was found in long‐term functional independence between stroke patients who received mechanical thrombectomy following inter‐hospital transfer compared to patients who present directly to a thrombectomy‐capable center. These findings emphasize that optimizing telestroke workflow can mitigate the adverse effects of delay during transportation for patients that present to remote hospitals in rural areas.
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