Objective
Seizure at onset (SaO) has been considered a relative contraindication for intravenous thrombolysis (IVT) in patients with acute ischemic stroke, although this appraisal is not evidence ...based. Here, we investigated the prognostic significance of SaO in patients treated with IVT for suspected ischemic stroke.
Methods
In this multicenter, IVT‐registry–based study we assessed the association between SaO and symptomatic intracranial hemorrhage (sICH, European Cooperative Acute Stroke Study II definition), 3‐month mortality, and 3‐month functional outcome on the modified Rankin Scale (mRS) using unadjusted and adjusted logistic regression, coarsened exact matching, and inverse probability weighted analyses.
Results
Among 10,074 IVT‐treated patients, 146 (1.5%) had SaO. SaO patients had significantly higher National Institutes of Health Stroke Scale score and glucose on admission, and more often female sex, prior stroke, and prior functional dependence than non‐SaO patients. In unadjusted analysis, they had generally less favorable outcomes. After controlling for confounders in adjusted, matched, and weighted analyses, all associations between SaO and any of the outcomes disappeared, including sICH (odds ratio ORunadjusted = 1.53 95% confidence interval (CI) = 0.74–3.14, ORadjusted = 0.52 95% CI = 0.13–2.16, ORmatched = 0.68 95% CI = 0.15–3.03, ORweighted = 0.95 95% CI = 0.39–2.32), mortality (ORunadjusted = 1.49 95% CI = 1.00–2.24, ORadjusted = 0.98 95% CI = 0.5–1.92, ORmatched = 1.13 95% CI = 0.55–2.33, ORweighted = 1.17 95% CI = 0.73–1.88), and functional outcome (mRS ≥ 3/ordinal mRS: ORunadjusted = 1.33 95% CI = 0.96–1.84/1.35 95% CI = 1.01–1.81, ORadjusted = 0.78 95% CI = 0.45–1.32/0.78 95% CI = 0.52–1.16, ORmatched = 0.75 95% CI = 0.43–1.32/0.45 95% CI = 0.10–2.06, ORweighted = 0.87 95% CI = 0.57–1.34/1.00 95% CI = 0.66–1.52). These results were consistent regardless of whether patients had an eventual diagnosis of ischemic stroke (89/146) or stroke mimic (57/146 SaO patients).
Interpretation
SaO was not an independent predictor of poor prognosis. Withholding IVT from patients with assumed ischemic stroke presenting with SaO seems unjustified. ANN NEUROL 2019;86:770–779
Abstract Background/objectives To assess the prognostic relevance of cardiac troponin T (cTnT) values and their serial changes as measured with a high-sensitivity assay in acute ischaemic stroke. ...Methods and results In total, 1016 consecutive acute ischaemic stroke patients were registered prospectively within a two-year period. High-sensitivity cTnT was quantitated on admission and the following day. Patients were stratified into three groups: below the 99th percentile of a healthy reference population (< 14 ng/l; n = 409), moderately elevated cTnT (below the median of remaining patients, 14–30 ng/l; n = 299) and high cTnT (> 30 ng/l; n = 308). Outcome measures were unfavourable outcome (modified Rankin Scale ≥ 2 at hospital discharge, n = 604) and in-hospital mortality (n = 36). Peak cTnT levels were significantly associated with unfavourable outcome (adjusted odds ratios versus reference for moderately elevated cTnT 1.7, 95% confidence interval CI 1.1–2.7 and for high cTnT 3.1, 95% CI 1.8–5.6). The optimal cut-off for determining unfavourable outcome proved to be 16 ng/l. Adding this cut-off to clinical variables led to a significant improvement of c-statistics (0.851 versus 0.838, p = 0.02). Dynamic changes (δ ≥ 50%) of cTnT were detected in 137 patients (13%). Multiple Cox regression analysis showed an independent association of dynamic changes in cTnT with in-hospital mortality (hazard ratio 2.3, 95% CI 1.1–4.7). The model-fitting (p < 0.001) and c-statistics (0.889 versus 0.863, p = 0.08) improved most after dynamic change in cTnT had been added to a regression model which included clinical variables alone. Conclusions Our study adds novel findings relevant for interpretation of highly sensitive cTnT assays in acute ischaemic stroke: a) Myocardial injury is detectable in more than half of patients; b) even moderately elevated cTnT is associated with unfavourable outcome (optimal cut-off 16 ng/l); and c) dynamic changes in cTnT indicate an increased risk of in-hospital death.
Background
Myocardial injury as indicated by cardiac troponin elevation is associated with poor prognosis in acute stroke patients. Coronary angiography (CAG) is the diagnostic gold-standard to ...rule-out underlying obstructive coronary artery disease (CAD) in these patients. However, weighing risks and benefits of coronary angiography (CAG) against each other is particularly challenging, because stroke patients undergoing CAG may have a higher risk for secondary intracranial bleeding. Current guidelines remain vague. Thus, the aim of this study was to analyze frequency of pathological findings of CAG and associated clinical factors.
Methods
We analyzed indications and frequency of CAG performed in acute ischemic stroke patients in clinical routine in two European tertiary care hospitals from 2011 to 2018. All data were obtained retrospectively. Multiple logistic regression analyses were performed to identify variables associated with absence of obstructive coronary artery disease defined as presence of at least one coronary vessel stenosis ≥ 50%.
Results
A total of 139 AIS patients underwent CAG. Frequent indications for CAG were suspected acute coronary syndrome (
N
= 114) or scheduled cardiac surgery (
N
= 25). Acute coronary stenting was applied in 51/139 patients. Among patients with suspected acute coronary syndrome, no obstructive CAD was found in 27/114 patients. Absence of obstructive CAD was associated with insular cortex lesions, no clinical symptoms for ACS, less than three cardiovascular risk factors, younger age and normal wall motion.
Conclusion
Several variables suggest absence of CAD in AIS patients and may help in clinical decision making in stroke patients with myocardial injury.
The World Stroke Organization (WSO) Brain & Heart Task Force developed the Brain & hEart globAl iniTiative (BEAT), a pilot feasibility implementation program to establish clinical collaborations ...between cardiologists and stroke physicians who work at large healthcare facilities.
The WSO BEAT pilot project focused on atrial fibrillation (AF) and patent foramen ovale (PFO) detection and management, and poststroke cardiovascular complications known as the stroke-heart syndrome. The program included 10 sites from 8 countries: Brazil, China, Egypt, Germany, Japan, Mexico, Romania, and the USA The primary composite feasibility outcome was the achievement of the following 3 implementation metrics (1) developing site-specific clinical pathways for the diagnosis and management of AF, PFO, and the stroke-heart syndrome; (2) establishing regular Neurocardiology rounds (e.g., monthly); and (3) incorporating a cardiologist to the stroke team. The secondary objectives were (1) to identify implementation challenges to guide a larger program and (2) to describe qualitative improvements.
The WSO BEAT pilot feasibility program achieved the prespecified primary composite outcome in 9 of 10 (90%) sites. The most common challenges were the limited access to specific medications (e.g., direct oral anticoagulants) and diagnostic (e.g., prolonged cardiac monitoring) or therapeutic (e.g., PFO closure devices) technologies. The most relevant qualitative improvement was the achievement of a more homogeneous diagnostic and therapeutic approach.
The WSO BEAT pilot program suggests that developing neurocardiology collaborations is feasible. The long-term sustainability of the WSO BEAT program and its impact on quality of stroke care and clinical outcomes needs to be tested in a larger and longer duration program.
Introduction
Cardiac troponin (hs-cTnT) is a sensitive marker of myocardial injury and has been linked to incident dementia. The underlying mechanism of that observation is still unknown. Given that ...severity of cerebral small vessel disease is a predictor of cognitive decline, we aimed to explore whether there is an association between hs-cTnT and severity of white matter lesions (WML) as a marker of cerebral small vessel disease in patients with ischemic stroke.
Methods
We analyzed consecutive acute ischemic stroke patients admitted to Charité-University Hospital, Berlin from 2011 to 2013. Severity of WML was graded on 3T-MRI using the age-related white matter severity score (ARWMS). Patients with hs-cTnT elevation suggestive of acute coronary syndrome (ACS) were excluded (hs-cTnT > 52 ng/l or dynamic change of hs-cTnT > 50%, ESC guideline). We performed unadjusted and adjusted quantile regression models to assess the association between increased hs-cTnT (dichotomized at the 99th percentile, 14 ng/l) and severity of WML.
Results
A total of 860 patients was analyzed (median age 73 years, 44.8% female, median ARWMS 6). Patients with elevated hs-cTnT had more extensive WML than those without (median ARWMS 8 vs. 5, adjusted beta for 50th percentile 1.12, 95% CI 0.41–1.84). The association between WML and hs-cTnT elevation was strongest in patients with severe WML (adjusted beta 1.77, 95% CI 0.26–3.27 for 80th WML percentile).
Conclusion
Elevated hs-cTnT levels were associated with extent of WML in acute stroke patients. Further studies are needed to assess whether hs-cTnT can be used to identify stroke patients at risk for cognitive decline.
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