In recent randomized controlled trials (RCTs) intra-arterial treatment (IAT) has been proven effective and safe for patients with acute ischemic stroke (AIS). So far, there seemed to be no ...interaction between older age (>80) and main treatment effect. We studied the association of older age with outcome and adverse events after IAT in a cohort of intra arterially treated patients.
Data from all AIS patients with proven proximal anterior circulation cerebral artery occlusion who were intra arterially treated between 2002 until the start of the MR CLEAN trial were studied retrospectively. Duration of the procedure, recanalization (Thrombolysis In Cerebral Infarction score (TICI)), early neurological recovery (i.e. decrease on NIHSS of ≥ 8 points) after one week or at discharge, good functional outcome at discharge by modified Rankin Scale (mRS ≤ 2) and the occurrence of neurological and non-neurological adverse events were assessed and the association with age was investigated. In total 315 patients met our inclusion criteria. Median age was 63 years (range 22-93) and 17 patients (5.4%) were over 80. Age was inversely associated with good functional outcome (adjusted Odds Ratio (aOR) 0.80, 95% CI: 0.66-0.98) for every 10 years increase of age. Age was not associated with longer duration of the procedure, lower recanalization rate or less early neurological recovery. The risk of all adverse events (aOR 1.27; 95% CI: 1.08-1.50) and non-neurological adverse events (aOR 1.34; 95% CI: 1.11-1.61) increased, but that of peri-procedural adverse events (aOR 0.79; 95% CI: 0.66-0.94) decreased with age.
Higher age is inversely associated with good functional outcome after IAT in patients with AIS. However, treatment related adverse events are not related to age. These findings may help decision making when considering treatment of older patients with AIS.
Objectives
Vertebrobasilar stenosis is frequent in patients with posterior circulation stroke and it increases risk of recurrence. We investigated feasibility of duplex ultrasonography (DUS) for ...screening for extracranial vertebral artery stenosis and compared it with CT angiography (CTA).
Materials and Methods
We gathered data on 337 consecutive patients who had DUS because of posterior circulation stroke or TIA. Matching CTA studies were retrieved and used as reference. Stenosis on CTA was considered “significant” if >50%, at DUS if Peak Systolic Velocity (PSV) > 140 cm/s for the V1 segment and PSV > 125 cm/s for the V2 segment. We determined the area under the ROC curve (AUROC). In addition, we calculated which PSV cut‐off value resulted in highest sensitivity with acceptable specificity.
Results
DUS was able to make an adequate measurement in 378 of 674 V1 segments and 673 of 674 V2 segments. DUS detected a significant stenosis in 52 of 378 V1 segments; 12 were confirmed by CTA (AUROC 0.73, 95% Confidence Interval 0.63–0.83). The optimal DUS PSV cut‐off value for this segment was 90 cm/s. For the V2 segment there were too few stenoses to allow reliable assessment of diagnostic characteristics of DUS.
Conclusions
Although DUS has a fair AUROC for detecting significant stenosis, adequate assessment of the V1 segment is often not possible due to anatomic difficulties. Assessment of the V2 segment is feasible but yielded few stenoses. Hence, we consider usefulness of DUS for screening of extracranial vertebral artery stenosis limited.
Although duplex ultrasonography is fairly capable of detecting significant extracranial vertebral artery stenosis, adequate assessment of the V1 segment is often not possible due to anatomic difficulties. Assessment of the V2 segment is feasible but yielded few stenoses. Hence, we consider usefulness of DUS for screening of extracranial vertebral artery stenosis limited.
A variety of sensory stimuli relieve restless legs syndrome symptoms. Because systematic evaluations of sensory stimulation in restless legs syndrome are largely lacking, we performed a randomized ...crossover study to evaluate the effect of external sensory stimulation on restless legs syndrome symptoms.
Eighteen patients underwent 3 consecutive suggestive immobilization tests with the order of the following 3 conditions randomly assigned: no electrical stimulation (condition 1), tactile and proprioceptive sensory stimulation (condition 2), and tactile sensory stimulation only (condition 3). Restless legs syndrome symptoms were quantified by visual analog scales, and periodic leg movements during wake were measured.
Baseline visual analogue scale score was 4.5 (range 0-60) in condition 1, 10.5 (range 0-96) in condition 2, and 8.5 in condition 3 (p = 0.21). There was a tendency towards a higher maximum visual analogue scale score and visual analogue scale score at the end of the suggested immobilization test in the conditions with tactile sensory stimulation, though not significant (p = 0.74 and p = 0.29, respectively). Fifteen patients suffered from periodic leg movements during wake. Median indices were 18 (range 0-145) in condition 1, 26 (range 0-190) in condition 2, and 49 (range 0-228) in condition 3 (p = 0.76).
We found a tendency towards less leg discomfort in the conditions in which an external sensory input was applied. This potential benefit of sensory stimuli on restless legs syndrome severity merits further investigation as this could open new ways towards a better pathophysiological understanding and non-pharmacological treatments.
Differences in clinical presentation of acute ischemic stroke between men and women may affect prehospital identification of anterior circulation large vessel occlusion (aLVO). We assessed sex ...differences in diagnostic performance of 8 prehospital scales to detect aLVO.
We analyzed pooled individual patient data from 2 prospective cohort studies (LPSS Leiden Prehospital Stroke Study and PRESTO Prehospital Triage of Patients With Suspected Stroke Study) conducted in the Netherlands between 2018 and 2019, including consecutive patients ≥18 years suspected of acute stroke who presented within 6 hours after symptom onset. Ambulance paramedics assessed clinical items from 8 prehospital aLVO detection scales: Los Angeles Motor Scale, Rapid Arterial Occlusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Cincinnati Prehospital Stroke Scale, Prehospital Acute Stroke Severity, gaze-face-arm-speech-time, Conveniently Grasped Field Assessment Stroke Triage, and Face-Arm-Speech-Time Plus Severe Arm or Leg Motor Deficit. We assessed the diagnostic performance of these scales for identifying aLVO at prespecified cut points for men and women.
Of 2358 patients with suspected stroke (median age, 73 years; 47% women), 231 (10%) had aLVO (100/1114 9% women and 131/1244 11% men). The area under the curve of the scales ranged from 0.70 (95% CI, 0.65-0.75) to 0.77 (95% CI, 0.73-0.82) in women versus 0.69 (95% CI, 0.64-0.73) to 0.75 (95% CI, 0.71-0.79) in men. Positive predictive values ranged from 0.23 (95% CI, 0.20-0.27) to 0.29 (95% CI, 0.26-0.31) in women versus 0.29 (95% CI, 0.24-0.33) to 0.37 (95% CI, 0.32-0.43) in men. Negative predictive values were similar (0.95 95% CI, 0.94-0.96 to 0.98 95% CI, 0.97-0.98 in women versus 0.94 95% CI, 0.93-0.95 to 0.96 95% CI, 0.94-0.97 in men). Sensitivity of the scales was slightly higher in women than in men (0.53 95% CI, 0.43-0.63 to 0.76 95% CI, 0.68-0.84 versus 0.49 95% CI, 0.40-0.57 to 0.63 95% CI, 0.55-0.73), whereas specificity was lower (0.79 95% CI, 0.76-0.81 to 0.87 95% CI, 0.84-0.89 versus 0.82 95% CI, 0.79-0.84 to 0.90 95% CI, 0.88-0.91). Rapid arterial occlusion evaluation showed the highest positive predictive values in both sexes (0.29 in women and 0.37 in men), reflecting the different event rates.
aLVO scales show similar diagnostic performance in both sexes. The rapid arterial occlusion evaluation scale may help optimize prehospital transport decision-making in men as well as in women with suspected stroke.
We investigated the impact of the Corona Virus Disease 2019 (COVID-19) pandemic and the resulting lockdown on reperfusion treatments and door-to-treatment times during the first surge in Dutch ...comprehensive stroke centers. Furthermore, we studied the association between COVID-19-status and treatment times.
We included all patients receiving reperfusion treatment in 17 Dutch stroke centers from May 11th, 2017, until May 11th, 2020. We collected baseline characteristics, National Institutes of Health Stroke Scale (NIHSS) at admission, onset-to-door time (ODT), door-to-needle time (DNT), door-to-groin time (DGT) and COVID-19-status at admission. Parameters during the lockdown (March 15th, 2020 until May 11th, 2020) were compared with those in the same period in 2019, and between groups stratified by COVID-19-status. We used nationwide data and extrapolated our findings to the increasing trend of EVT numbers since May 2017.
A decline of 14% was seen in reperfusion treatments during lockdown, with a decline in both IVT and EVT delivery. DGT increased by 12 min (50 to 62 min, p-value of < 0.001). Furthermore, median NIHSS-scores were higher in COVID-19 - suspected or positive patients (7 to 11, p-value of 0.004), door-to-treatment times did not differ significantly when stratified for COVID-19-status.
During the first surge of the COVID-19 pandemic, a decline in acute reperfusion treatments and a delay in DGT was seen, which indicates a target for attention. It also appeared that COVID-19-positive or -suspected patients had more severe neurologic symptoms, whereas their EVT-workflow was not affected.
Background: Intra-arterial treatment is increasingly used in acute ischemic stroke. Recently, new devices have become available, aiming at better recanalization rates and outcome. We present a series ...of patients with acute stroke of the anterior circulation treated with intra-arterial therapy using intra-arterial thrombolysis and different types of mechanical devices. Methods: We prospectively gathered clinical and radiological data of all patients with acute anterior stroke who were treated with intra-arterial therapy in a Dutch teaching hospital between 2009 and 2011. Patients were grouped according to the intra-arterial treatment strategy and analyzed for poor outcome (modified Rankin Scale score >2 or death), complications and recanalization rate with the Poisson regression. Results: Eighty-four patients were treated with intra-arterial therapy, 13 with intra-arterial thrombolysis only (ND group), 22 with a Merci device (MERCI group) and 49 with a stent retriever (SR group). Overall, 52 patients (62%) had poor outcome of whom 17 (20%) died. There was a trend towards poorer outcome in the ND group (adjusted RR 1.18; 95% CI 0.74-1.88) and the MERCI group (adjusted RR 1.17; 95% CI 0.79-1.74) compared with the SR group. Furthermore, failed recanalization occurred more often in the ND group (adjusted RR 2.59; 95% CI 1.50-4.49) and MERCI group (adjusted RR 2.32; 95% CI 1.33-4.05) compared with the SR group. Conclusion: We found higher recanalization rates with SRs. However, this resulted only in a trend towards better clinical outcome.
The value of administering intravenous alteplase before endovascular treatment (EVT) for acute ischemic stroke has not been studied extensively, particularly in non-Asian populations.
We performed an ...open-label, multicenter, randomized trial in Europe involving patients with stroke who presented directly to a hospital that was capable of providing EVT and who were eligible for intravenous alteplase and EVT. Patients were randomly assigned in a 1:1 ratio to receive EVT alone or intravenous alteplase followed by EVT (the standard of care). The primary end point was functional outcome on the modified Rankin scale (range, 0 no disability to 6 death) at 90 days. We assessed the superiority of EVT alone over alteplase plus EVT, as well as noninferiority by a margin of 0.8 for the lower boundary of the 95% confidence interval for the odds ratio of the two trial groups. Death from any cause and symptomatic intracerebral hemorrhage were the main safety end points.
The analysis included 539 patients. The median score on the modified Rankin scale at 90 days was 3 (interquartile range, 2 to 5) with EVT alone and 2 (interquartile range, 2 to 5) with alteplase plus EVT. The adjusted common odds ratio was 0.84 (95% confidence interval CI, 0.62 to 1.15; P = 0.28), which showed neither superiority nor noninferiority of EVT alone. Mortality was 20.5% with EVT alone and 15.8% with alteplase plus EVT (adjusted odds ratio, 1.39; 95% CI, 0.84 to 2.30). Symptomatic intracerebral hemorrhage occurred in 5.9% and 5.3% of the patients in the respective groups (adjusted odds ratio, 1.30; 95% CI, 0.60 to 2.81).
In a randomized trial involving European patients, EVT alone was neither superior nor noninferior to intravenous alteplase followed by EVT with regard to disability outcome at 90 days after stroke. The incidence of symptomatic intracerebral hemorrhage was similar in the two groups. (Funded by the Collaboration for New Treatments of Acute Stroke consortium and others; MR CLEAN-NO IV ISRCTN number, ISRCTN80619088.).
Aspirin and unfractionated heparin are often used during endovascular stroke treatment to improve reperfusion and outcomes. However, the effects and risks of anti-thrombotics for this indication are ...unknown. We therefore aimed to assess the safety and efficacy of intravenous aspirin, unfractionated heparin, both, or neither started during endovascular treatment in patients with ischaemic stroke.
We did an open-label, multicentre, randomised controlled trial with a 2 × 3 factorial design in 15 centres in the Netherlands. We enrolled adult patients (ie, ≥18 years) with ischaemic stroke due to an intracranial large-vessel occlusion in the anterior circulation in whom endovascular treatment could be initiated within 6 h of symptom onset. Eligible patients had a score of 2 or more on the National Institutes of Health Stroke Scale, and a CT or MRI ruling out intracranial haemorrhage. Randomisation was done using a web-based procedure with permuted blocks and stratified by centre. Patients were randomly assigned (1:1) to receive either periprocedural intravenous aspirin (300 mg bolus) or no aspirin, and randomly assigned (1:1:1) to receive moderate-dose unfractionated heparin (5000 IU bolus followed by 1250 IU/h for 6 h), low-dose unfractionated heparin (5000 IU bolus followed by 500 IU/h for 6 h), or no unfractionated heparin. The primary outcome was the score on the modified Rankin Scale at 90 days. Symptomatic intracranial haemorrhage was the main safety outcome. Analyses were based on intention to treat, and treatment effects were expressed as odds ratios (ORs) or common ORs, with adjustment for baseline prognostic factors. This trial is registered with the International Standard Randomised Controlled Trial Number, ISRCTN76741621.
Between Jan 22, 2018, and Jan 27, 2021, we randomly assigned 663 patients; of whom, 628 (95%) provided deferred consent or died before consent could be asked and were included in the modified intention-to-treat population. On Feb 4, 2021, after unblinding and analysis of the data, the trial steering committee permanently stopped patient recruitment and the trial was stopped for safety concerns. The risk of symptomatic intracranial haemorrhage was higher in patients allocated to receive aspirin than in those not receiving aspirin (43 14% of 310 vs 23 7% of 318; adjusted OR 1·95 95% CI 1·13–3·35) as well as in patients allocated to receive unfractionated heparin than in those not receiving unfractionated heparin (44 13% of 332 vs 22 7% of 296; 1·98 1·14–3·46). Both aspirin (adjusted common OR 0·91 95% CI 0·69–1·21) and unfractionated heparin (0·81 0·61–1·08) led to a non-significant shift towards worse modified Rankin Scale scores.
Periprocedural intravenous aspirin and unfractionated heparin during endovascular stroke treatment are both associated with an increased risk of symptomatic intracranial haemorrhage without evidence for a beneficial effect on functional outcome.
The Collaboration for New Treatments of Acute Stroke consortium, the Brain Foundation Netherlands, the Ministry of Economic Affairs, Stryker, Medtronic, Cerenovus, and the Dutch Heart Foundation.
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