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  • 1
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    Online Resource
    Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants
    American Medical Association (AMA) ; 2023
    In:  JAMA Neurology Vol. 80, No. 3 ( 2023-03-01), p. 233-
    Details
    In: JAMA Neurology, American Medical Association (AMA), Vol. 80, No. 3 ( 2023-03-01), p. 233-
    Abstract: International guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC). Objective To determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion. Design, Setting, and Participants This international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021. Exposures Prior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation. Main Outcomes and Measures The main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses. Results Of 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion. Conclusions and Relevance In this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.
    Type of Medium: Online Resource
    ISSN: 2168-6149
    URL: Article
    DOI: 10.1001/jamaneurol.2022.4782
    Language: English
    Publisher: American Medical Association (AMA)
    Publication Date: 2023
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  • 2
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    Chronic cerebral infarctions and white matter lesions link to long‐term survival after a first ischemic event: A cohort study
    Wiley ; 2022
    In:  Journal of Neuroimaging Vol. 32, No. 6 ( 2022-11), p. 1134-1141
    Details
    In: Journal of Neuroimaging, Wiley, Vol. 32, No. 6 ( 2022-11), p. 1134-1141
    Abstract: To investigate the association of different phenotypes, count, and locations of chronic covert brain infarctions (CBI) with long‐term mortality in patients with first‐ever manifest acute ischemic stroke (AIS) or transient ischemic attack (TIA). Additionally, to analyze their potential interaction with white matter hyperintensities (WMH) and predictive value in addition to established mortality scores. Methods Single‐center cohort study including consecutive patients with first‐ever AIS or TIA with available MRI imaging from January 2015 to December 2017. Blinded raters adjudicated CBI phenotypes and WMH (age‐related white matter changes score) according to established definitions. We compared Cox regression models including prespecified established predictors of mortality using Harrell's C and likelihood ratio tests. Results A total of 2236 patients (median [interquartile range] age: 71 [59‐80] years, 43% female, National Institutes of Health Stroke Scale: 2 [1‐6], median follow‐up: 1436 days, 21% death during follow‐up) were included. Increasing WMH (per point adjusted Hazard Ratio [aHR]  = 1.29 [1.14‐1.45]), but not CBI (aHR = 1.21 [0.99‐1.49] ), were independently associated with mortality. Neither CBI phenotype, count, nor location was associated with mortality and there was no multiplicative interaction between CBI and WMH ( p   〉  .1). As compared to patients without CBI or WMH, patients with moderate or severe WMH and additional CBI had the highest hazards of death (aHR = 1.62 [1.23‐2.13]). The Cox regression model including CBI and WMH had a small but significant increment in Harrell's C when compared to the model including 14 clinical variables (0.831 vs. 0.827, p   〈  .001). Discussion WMH represent a strong surrogate biomarker of long‐term mortality in first‐ever manifest AIS or TIA patients. CBI phenotypes, count, and location seem less relevant. Incorporation of CBI and WMH slightly improves predictive capacity of established risk scores.
    Type of Medium: Online Resource
    ISSN: 1051-2284 , 1552-6569
    URL: Issue
    URL: Article
    DOI: 10.1111/jon.v32.6
    DOI: 10.1111/jon.13033
    Language: English
    Publisher: Wiley
    Publication Date: 2022
    detail.hit.zdb_id: 2035400-9
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  • 3
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    Data_Sheet_2.PDF
    Frontiers Media SA ; 2022
    In:  Frontiers in Neurology Vol. 13 ( 2022-7-14)
    Details
    In: Frontiers in Neurology, Frontiers Media SA, Vol. 13 ( 2022-7-14)
    Abstract: Clots rich in platelets and fibrin retrieved from patients with acute ischemic stroke (AIS) have been shown to be independently associated with the absence of the susceptibility vessel sign (SVS) on MRI and active malignancy. This study analyzed the association of SVS and the presence of active malignancy in patients with AIS who underwent mechanical thrombectomy (MT). Methods This single-center, retrospective, and cross-sectional study included consecutive patients with AIS with admission MRI treated with MT between January 2010 and December 2018. SVS status was evaluated on susceptibility-weighted imaging. Adjusted odds ratios (aORs) were calculated to determine the association between absent SVS and the presence of active or occult malignancy. The performance of predictive models incorporating and excluding SVS status was compared using areas under the receiver operating characteristics curve (auROC). Results Of 577 patients with AIS with assessable SVS status, 40 (6.9%) had a documented active malignancy and 72 (12.5%) showed no SVS. The absence of SVS was associated with active malignancy (aOR 4.85, 95% CI 1.94–12.11) or occult malignancy (aOR 11.42, 95% CI 2.36–55.20). The auROC of predictive models, including demographics and common malignancy biomarkers, was higher but not significant (0.85 vs. 0.81, p = 0.07) when SVS status was included. Conclusion Absence of SVS on admission MRI of patients with AIS undergoing MT is associated with malignancy, regardless of whether known or occult. Therefore, the SVS might be helpful in detecting paraneoplastic coagulation disorders and occult malignancy in patients with AIS.
    Type of Medium: Online Resource
    ISSN: 1664-2295
    URL: Article
    URL: Article
    URL: Article
    DOI: 10.3389/fneur.2022.930635
    DOI: 10.3389/fneur.2022.930635.s001
    DOI: 10.3389/fneur.2022.930635.s002
    Language: Unknown
    Publisher: Frontiers Media SA
    Publication Date: 2022
    detail.hit.zdb_id: 2564214-5
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  • 4
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    Long-Term Effect of Mechanical Thrombectomy in Stroke Patients According to Advanced Imaging Characteristics.
    Springer Science and Business Media LLC ; 2023
    In:  Clinical Neuroradiology
    Details
    In: Clinical Neuroradiology, Springer Science and Business Media LLC
    Abstract: Data on long-term effect of mechanical thrombectomy (MT) in patients with large ischemic cores (≥ 70 ml) are scarce. Our study aimed to assess the long-term outcomes in MT-patients according to baseline advanced imaging parameters. Methods We performed a single-centre retrospective cohort study of stroke patients receiving MT between January 1, 2010 and December 31, 2018. We assessed baseline imaging to determine core and mismatch volumes and hypoperfusion intensity ratio (with low ratio reflecting good collateral status) using RAPID automated post-processing software. Main outcomes were cross-sectional long-term mortality, functional outcome and quality of life by May 2020. Analysis were stratified by the final reperfusion status. Results In total 519 patients were included of whom 288 (55.5%) have deceased at follow-up (median follow-up time 28 months, interquartile range 1–55). Successful reperfusion was associated with lower long-term mortality in patients with ischemic core volumes ≥ 70 ml (adjusted hazard ratio (aHR) 0.20; 95% confidence interval (95% CI) 0.10–0.44) and ≥ 100 ml (aHR 0.26; 95% CI 0.08–0.87). The effect of successful reperfusion on long-term mortality was significant only in the presence of relevant mismatch (aHR 0.17; 95% CI 0.01–0.44). Increasing reperfusion grade was associated with a higher rate of favorable outcomes (mRS 0–3) also in patients with ischemic core volume ≥ 70 ml (aOR 3.58, 95% CI 1.64–7.83). Conclusion Our study demonstrated a sustainable benefit of better reperfusion status in patients with large ischemic core volumes. Our results suggest that patient deselection based on large ischemic cores alone is not advisable.
    Type of Medium: Online Resource
    ISSN: 1869-1439 , 1869-1447
    URL: Article
    DOI: 10.1007/s00062-023-01337-4
    Language: English
    Publisher: Springer Science and Business Media LLC
    Publication Date: 2023
    detail.hit.zdb_id: 2232347-8
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  • 5
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    Development of a Score for Prediction of Occult Malignancy in Stroke Patients (Occult-5 Score)
    Elsevier BV ; 2022
    In:  Journal of Stroke and Cerebrovascular Diseases Vol. 31, No. 8 ( 2022-08), p. 106609-
    Details
    In: Journal of Stroke and Cerebrovascular Diseases, Elsevier BV, Vol. 31, No. 8 ( 2022-08), p. 106609-
    Type of Medium: Online Resource
    ISSN: 1052-3057
    URL: Article
    DOI: 10.1016/j.jstrokecerebrovasdis.2022.106609
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2022
    detail.hit.zdb_id: 2052957-0
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  • 6
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    Phenotypes of Chronic Covert Brain Infarction in Patients With First-Ever Ischemic Stroke: A Cohort Study
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Stroke Vol. 53, No. 2 ( 2022-02), p. 558-568
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 53, No. 2 ( 2022-02), p. 558-568
    Abstract: The aim of this study was to assess the rate of chronic covert brain infarctions (CBIs) in patients with acute ischemic stroke (AIS) and to describe their phenotypes and diagnostic value. Methods: This is a single-center cohort study including 1546 consecutive patients with first-ever AIS on magnetic resonance imaging imaging from January 2015 to December 2017. The main study outcomes were CBI phenotypes, their relative frequencies, location, and association with vascular risk factors. Results: Any CBI was present in 574/1546 (37% [95% CI, 35%–40%]) of patients with a total of 950 CBI lesions. The most frequent locations of CBI were cerebellar in 295/950 (31%), subcortical supratentorial in 292/950 (31%), and cortical in 213/950 (24%). CBI phenotypes included lacunes (49%), combined gray and white matter lesions (30%), gray matter lesions (13%), and large subcortical infarcts (7%). Vascular risk profile and white matter hyperintensities severity (19% if no white matter hyperintensity, 63% in severe white matter hyperintensity, P 〈 0.001) were associated with presence of any CBI. Atrial fibrillation was associated with cortical lesions (adjusted odds ratio, 2.032 [95% CI, 1.041–3.967]). Median National Institutes of Health Stroke Scale scores on admission were higher in patients with an embolic CBI phenotype (median National Institutes of Health Stroke Scale, 5 [2–10] , P =0.025). Conclusions: CBIs were present in more than a third of patients with first AIS. Their location and phenotypes as determined by MRI were different from previous studies using computed tomography imaging. Among patients suffering from AIS, those with additional CBI represent a vascular high-risk subgroup and the association of different phenotypes of CBIs with differing risk factor profiles potentially points toward discriminative AIS etiologies.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.121.034347
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
    detail.hit.zdb_id: 1467823-8
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  • 7
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    Abstract TMP3: Prediction Model For Medical Rescue Treatment Strategies In Patients With Incomplete Reperfusion
    Ovid Technologies (Wolters Kluwer Health) ; 2023
    In:  Stroke Vol. 54, No. Suppl_1 ( 2023-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 54, No. Suppl_1 ( 2023-02)
    Abstract: Background: After successful reperfusion is achieved (extended Thrombolysis in Cerebral Infarction (eTICI) ≥2b50), decision on pursuing additional treatment strategies in order to achieve complete reperfusion (eTICI=2c/3), is multifactorial and depends on patient’s clinical and imaging characteristics. We have developed and validated a clinical decision tool to provide individualized predictions on achieving delayed reperfusion based on individual patient data. Methods: Single-center registry analysis for all consecutive patients admitted between 02/2015 - 12/2020. Primary variable of interest was perfusion imaging outcome in patients with incomplete reperfusion (eTICI 2a-2c), evaluated on the 24-hour follow-up imaging. This variable was dichotomized into delayed reperfusion, in case of non-observable perfusion deficit, and persistent perfusion deficit, in case of perfusion deficit captured on the final angiography imaging. Final model variable selection was performed via bootstrapped (n=200) stepwise backwards regression. Model was split into a training and testing set (80:20 ratio), with 10-fold cross validation resampling. Results: 372 patients (50.8% female, mean age 74) were included, with 228 (61.2%) of them having delayed reperfusion. Final model identified seven variables of importance including: age, sex, atrial fibrillation, Intervention-to-Follow-Up time, maneuver count, eTICI and collateral status. Model’s discriminative ability for predicting delayed reperfusion was adequate (AUC 0.83, 95% CI 0.74 -0.92), with an overall adjusted calibration (Brier score 0.17, 95% CI 0.15-0.18). Conclusions: Current model presents a tool that may aid clinical decision-making process in selection of patients for pursuing additional treatment strategies after incomplete reperfusion has been achieved. This is an important next step towards personalized treatment of stroke patients undergoing mechanical thrombectomy.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.54.suppl_1.TMP3
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2023
    detail.hit.zdb_id: 1467823-8
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  • 8
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    Association of the 24‐Hour National Institutes of Health Stroke Scale After Mechanical Thrombectomy With Early and Long‐Term Survival
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Stroke: Vascular and Interventional Neurology Vol. 2, No. 4 ( 2022-07)
    Details
    In: Stroke: Vascular and Interventional Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 2, No. 4 ( 2022-07)
    Abstract: The National Institutes of Health Stroke Scale (NIHSS) obtained 24 hours after ischemic stroke is a good indicator for functional outcome and early mortality, but the correlation with long‐term survival is less clear. We analyzed the correlation of the NIHSS after 24 hours (24h NIHSS) and early clinical neurological development after mechanical thrombectomy with early and long‐term survival as well as its predictive power on survival. Methods We reviewed a prospective observational registry for all patients undergoing mechanical thrombectomy between January 2010 and December 2018. Vital status was extracted from the Swiss Population Registry. Adjusted hazard ratio (aHR) and crude hazard ratios were calculated using Cox regression. To assess predictive power of the 24h NIHSS, different Random Survival Forest models were evaluated. Results We included 957 patients (median follow‐up 1376 days). Patients with lower 24h NIHSS and major early neurological improvement had substantially better survival rates. We observed significantly higher aHR for death in patients with 24h NIHSS 12 to 15 (aHR, 1.78; 95% CI, 1.1–2.89), with 24h NIHSS 16 to 21 (aHR, 2.54, 95% CI, 1.59–4.06), and with 24h NIHSS 〉 21 (aHR, 5.74; 95% CI, 3.47–9.5). The 24h NIHSS showed the best performance predicting mortality (receiver operating characteristic area under the curve at 3 months [0.85±0.034], at 1 year [0.82±0.029] , at 2 years [0.82±0.031], and at 5 years [0.83±0.035] ), followed by NIHSS change. Conclusions Patients with acute ischemic stroke achieving a low 24h NIHSS or major early neurological improvement after mechanical thrombectomy had markedly lower long‐term mortality. Furthermore, 24h NIHSS had the best predictive power for early and long‐term survival in our machine learning–based prediction.
    Type of Medium: Online Resource
    ISSN: 2694-5746
    URL: Article
    DOI: 10.1161/SVIN.121.000244
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
    detail.hit.zdb_id: 3144224-9
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  • 9
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    Abstract 1122‐000084: Does Intravenous Thrombolysis Promote Delayed Reperfusion After Incomplete Mechanical Thrombectomy?
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Stroke: Vascular and Interventional Neurology Vol. 1, No. S1 ( 2021-11)
    Details
    In: Stroke: Vascular and Interventional Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 1, No. S1 ( 2021-11)
    Abstract: Introduction : The value of intravenous thrombolysis (IVT) in patients eligible for mechanical thrombectomy (MT) remains unclear. We hypothesized that pre‐treatment with and/or ongoing IVT may facilitate reperfusion of distal vessel occlusion after incomplete MT. We evaluated this potential association using follow‐up perfusion imaging. Methods : Retrospective observational analysis of our institution`s stroke registry included patients with incomplete reperfusion after MT, admitted between February 1, 2015 and December 8, 2020. Delayed reperfusion (DR) was defined as the absence of a persistent perfusion deficit on contrast‐enhanced perfusion imaging ⁓24h±12h after the intervention. The association between baseline parameters and the occurrence of DR was evaluated using a logistic regression analyses. To account for possible time‐dependent associations of IVT with DR, additional stratification sets were made based on different time windows between IVT start time and final angiography runs. Results : Among the 378 included patients (median age 73.5, 50.8% female), DR occurred in 226 (59.8%). Atrial fibrillation (aOR 2.53 [95% CI 1.34 ‐ 4.90]), eTICI score (aOR 3.79 [95% CI 2.71 ‐ 5.48] per TICI grade increase), and intervention‐to‐follow‐up time (aOR 1.08 [95% CI 1.04 ‐ 1.13] per hour delay) were associated with DR. Dichotomized IVT strata showed no association with DR (aOR 0.75 [95% CI 0.42 ‐ 1.33] ), whereas shorter intervals between IVT start and end of the procedure showed a borderline significant association with DR (OR 2.24 [95% CI 0.98 ‐ 5.43, and OR 2.07 [95% 1.06 – 4.31], for 80 and 100 minutes respectively). Patients with DR had higher rates of functional independence (modified Rankin scale 0–2 at 90 days, DR: 63.3% vs PPD: 38.8%; p 〈 0.01) and longer survival time (at 3 years, DR: 69.2% vs PPD: 45.8%; p = 0.001). Conclusions : There is weak evidence that IVT may favor DR after incomplete MT if the time interval between IVT administration and end of the procedure is short. In general, perfusion follow‐up imaging may constitute a suitable surrogate parameter for evaluating medical rescue strategies after incomplete MT, because a considerable proportion of patients do not experience DR, and there seems to be a close correlation with clinical outcomes.
    Type of Medium: Online Resource
    ISSN: 2694-5746
    URL: Article
    DOI: 10.1161/SVIN.01.suppl_1.000084
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
    detail.hit.zdb_id: 3144224-9
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  • 10
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    Impact of sex in stroke in the young
    Public Library of Science (PLoS) ; 2023
    In:  PLOS ONE Vol. 18, No. 3 ( 2023-3-31), p. e0274722-
    Details
    In: PLOS ONE, Public Library of Science (PLoS), Vol. 18, No. 3 ( 2023-3-31), p. e0274722-
    Abstract: Limited data is available on sex differences in young stroke patients describing discrepant findings. This study aims to investigate the sex differences in young stroke patients. Methods Prospective cohort study comparing risk factors, etiology, stroke localization, severity on admission, management and outcome in patients aged 16–55 years with acute ischemic stroke consecutively included in the Bernese stroke database between 01/2015 to 12/2018 with subgroup analyses for very young (16-35y) and young patients (36-55y). Results 689 patients (39% female) were included. Stroke in women dominated in the very young (53.8%, p 〈 0.001) and in men in the young (63.9%, p 〈 0.001). As risk factors only sleep-disordered breathing was more predominant in men in the very young, whereas arterial hypertension, diabetes and atrial fibrillation did not differ in women and men older than 35y. The higher frequency of stroke in women in the very young may be explained by the sex specific risk factors such as pregnancy, puerperium, the use of oral contraceptives, and hormonal replacement therapy. Stroke severity at presentation, etiology, stroke localization, management, and outcome did not differ between women and men. Conclusions The main finding of this study is that sex specific risk factors in women may contribute to a large extent to the higher incidence of stroke in the very young in women. Important modifiable stroke risk factors, such as arterial hypertension, diabetes mellitus and atrial fibrillation did not differ in women and men, either in the young as well as in the very young. These findings have major implications for primary preventive strategies of stroke in young people.
    Type of Medium: Online Resource
    ISSN: 1932-6203
    URL: Article
    URL: Article
    URL: Article
    URL: Article
    URL: Article
    URL: Article
    URL: Article
    URL: Article
    DOI: 10.1371/journal.pone.0274722
    DOI: 10.1371/journal.pone.0274722.g001
    DOI: 10.1371/journal.pone.0274722.g002
    DOI: 10.1371/journal.pone.0274722.t001
    DOI: 10.1371/journal.pone.0274722.t002
    DOI: 10.1371/journal.pone.0274722.s001
    DOI: 10.1371/journal.pone.0274722.s002
    DOI: 10.1371/journal.pone.0274722.s003
    Language: English
    Publisher: Public Library of Science (PLoS)
    Publication Date: 2023
    detail.hit.zdb_id: 2267670-3
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