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  • 1
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    Embolic strokes of undetermined source: theoretical construct or useful clinical tool?
    SAGE Publications ; 2019
    In:  Therapeutic Advances in Neurological Disorders Vol. 12 ( 2019-01), p. 175628641985138-
    Details
    In: Therapeutic Advances in Neurological Disorders, SAGE Publications, Vol. 12 ( 2019-01), p. 175628641985138-
    Abstract: In 2014, the definition of embolic strokes of undetermined source (ESUS) emerged as a new clinical construct to characterize cryptogenic stroke (CS) patients with complete vascular workup to determine nonlacunar, nonatherosclerotic strokes of presumable embolic origin. NAVIGATE ESUS, the first phase III randomized-controlled, clinical trial (RCT) comparing rivaroxaban (15 mg daily) with aspirin (100 mg daily), was prematurely terminated for lack of efficacy after enrollment of 7213 patients. Except for the lack of efficacy in the primary outcome, rivaroxaban was associated with increased risk of major bleeding and hemorrhagic stroke compared with aspirin. RE-SPECT ESUS was the second phase III RCT that compared the efficacy and safety of dabigatran (110 or 150 mg, twice daily) to aspirin (100 mg daily). The results of this trial have been recently presented and showed similar efficacy and safety outcomes between dabigatran and aspirin. Indirect analyses of these trials suggest similar efficacy on the risk of ischemic stroke (IS) prevention, but higher intracranial hemorrhage risk in ESUS patients receiving rivaroxaban compared to those receiving dabigatran (indirect HR = 6.63, 95% CI: 1.38–31.76). ESUS constitute a heterogeneous group of patients with embolic cerebral infarction. Occult AF represents the underlying mechanism of cerebral ischemia in the minority of ESUS patients. Other embolic mechanisms (paradoxical embolism via patent foramen ovale, aortic plaque, nonstenosing unstable carotid plaque, etc.) may represent alternative mechanisms of cerebral embolism in ESUS, and may mandate different management than oral anticoagulation. The potential clinical utility of ESUS may be challenged since the concept failed to identify patients who would benefit from anticoagulation therapy. Compared with the former diagnosis of CS, ESUS patients required thorough investigations; more comprehensive diagnostic work-up than is requested in current ESUS diagnostic criteria may assist clinicians in uncovering the source of brain embolism in CS patients and individualize treatment approaches.
    Type of Medium: Online Resource
    ISSN: 1756-2864 , 1756-2864
    URL: Article
    DOI: 10.1177/1756286419851381
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2019
    detail.hit.zdb_id: 2442245-9
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  • 2
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    Neurological manifestations and implications of COVID-19 pandemic
    SAGE Publications ; 2020
    In:  Therapeutic Advances in Neurological Disorders Vol. 13 ( 2020-01), p. 175628642093203-
    Details
    In: Therapeutic Advances in Neurological Disorders, SAGE Publications, Vol. 13 ( 2020-01), p. 175628642093203-
    Abstract: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China and rapidly spread worldwide, with a vast majority of confirmed cases presenting with respiratory symptoms. Potential neurological manifestations and their pathophysiological mechanisms have not been thoroughly established. In this narrative review, we sought to present the neurological manifestations associated with coronavirus disease 2019 (COVID-19). Case reports, case series, editorials, reviews, case-control and cohort studies were evaluated, and relevant information was abstracted. Various reports of neurological manifestations of previous coronavirus epidemics provide a roadmap regarding potential neurological complications of COVID-19, due to many shared characteristics between these viruses and SARS-CoV-2. Studies from the current pandemic are accumulating and report COVID-19 patients presenting with dizziness, headache, myalgias, hypogeusia and hyposmia, but also with more serious manifestations including polyneuropathy, myositis, cerebrovascular diseases, encephalitis and encephalopathy. However, discrimination between causal relationship and incidental comorbidity is often difficult. Severe COVID-19 shares common risk factors with cerebrovascular diseases, and it is currently unclear whether the infection per se represents an independent stroke risk factor. Regardless of any direct or indirect neurological manifestations, the COVID-19 pandemic has a huge impact on the management of neurological patients, whether infected or not. In particular, the majority of stroke services worldwide have been negatively influenced in terms of care delivery and fear to access healthcare services. The effect on healthcare quality in the field of other neurological diseases is additionally evaluated.
    Type of Medium: Online Resource
    ISSN: 1756-2864 , 1756-2864
    URL: Article
    DOI: 10.1177/1756286420932036
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2020
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  • 3
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    Abstract 156: Intravenous Thrombolysis for Acute Ischemic Stroke in the Golden Hour: A Systematic Review and Meta-Analysis
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Stroke Vol. 49, No. Suppl_1 ( 2018-01-22)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 49, No. Suppl_1 ( 2018-01-22)
    Abstract: Introduction: Data are scarce regarding the outcomes of acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT) within 60 min from symptom onset, termed the “golden hour” (GH) window. We present systematic review and meta-analysis of outcomes between AIS patients treated within (+) and outside (-) the GH. Methods: We performed a systematic review in MEDLINE and SCOPUS databases for observational studies providing unadjusted rates or adjusted odds ratios (OR) for the following outcomes: symptomatic intracranial hemorrhage (sICH), mortality and favourable functional outcome (FFO), defined as mRS-scores of 0-1. Results: We identified 3 eligible studies (range of median NIHSS-scores: 10-11 points), including a total of 72,662 IVT-treated patients (1.5% treated within the GH. GH(+) patients had higher FFO rates (42%, 95%CI:35%-48%) compared to GH(-) patients (31%, 95%CI:30%-31%). In adjusted analyses, IVT within the GH was associated with a two-fold increase in the odds of FFO (OR=2.02, 95%CI: 1.55-2.63, p 〈 0.001) without heterogeneity across studies (I 2 =0, p for Cochran Q=0.93; Figure). No significant differences on the risk of both sICH (OR=0.77, 95%CI: 0.53-1.13, p=0.180; I 2 =0, p for Cochran Q=0.63) and mortality (OR=0.61, 95%CI: 0.29-1.28, p=0.190; I 2 =72, p for Cochran Q=0.03) were documented between the two groups in adjusted analyses. Conclusions: AIS treated within the GH have substantially higher odds of FFO compared to IVT administered later during conventional time window independent of potential confounders. Improvement of care systems to achieve the earliest onset to treatment times should remain the goal of the front line stroke treatment.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.49.suppl_1.156
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
    detail.hit.zdb_id: 1467823-8
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  • 4
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    Abstract 145: Advanced Neuroimaging in Stroke Patient Selection for Mechanical Thrombectomy: A Systematic Review and Meta-analysis
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Stroke Vol. 50, No. Suppl_1 ( 2019-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 50, No. Suppl_1 ( 2019-02)
    Abstract: Introduction: There is clinical equipoise regarding the use of advanced imaging for selecting acute ischemic stroke (AIS) patients eligible for mechanical thrombectomy (MT) during the first 6 hours from symptom onset. However, accumulating evidence indicates that advanced neuroimaging represents an invaluable and time independent prognostic factor. Methods: We performed a systematic review and meta-analysis of available randomized clinical trials (RCTs) to evaluate the impact of patient selection with advanced neuroimaging on the 3-month: 1. functional independence (FI, mRS: 0-2), 2. favorable functional outcome [FFO, modified Rankin Scale scores (mRS): 0-1], 3. all-cause mortality and 4. functional improvement (assessed with ordinal analysis of the mRS-scores). Results: Among the 10 eligible RCTs (1979 total patients, mean age: 67 years), 5 studies reported the use of advanced imaging. Studies using advanced neuroimaging showed higher treatment effects of MT on 3-month FI (OR=3.79, 95%CI: 2.71-5.28 vs. OR=1.76, 95%CI: 1.39-2.24; p for subgroup differences 〈 0.001), FFO (OR=3.16, 95%CI: 1.94-5.14 vs. OR=1.75, 95%CI: 1.30-2.34; p for subgroup differences=0.04) and functional improvement (cOR=2.77, 95%CI: 2.04-3.76 vs. 1.60, 95%CI: 1.32-1.95; p for subgroup differences: 0.003) compared to studies using conventional neuroimaging. Including only studies in the early (0-8hrs) time window advanced imaging selection was associated with better 3-month FI rates (p for subgroup differences: 0.04) compared to conventional imaging selection. No difference in the mortality (p for subgroup differences: 0.27) and sICH rates (p for subgroup differences 0.93) was found between the two groups. No evidence of heterogeneity was documented in all the aforementioned subgroups (I 2 〈 30%, p for Cochran Q 〉 0.17 for all analyses). Conclusions: Our findings indicate that AIS patient selection for MT based on advanced neuroimaging appears to be associated with improved clinical outcomes, including lower mortality rates. The use of advanced neuroimaging for both the selection and prediction of prognosis for MT candidates should not depend on the elapsed time from symptom onset.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.50.suppl_1.145
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
    detail.hit.zdb_id: 1467823-8
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  • 5
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    Successful Reperfusion With Intravenous Thrombolysis Preceding Mechanical Thrombectomy in Large-Vessel Occlusions
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Stroke Vol. 49, No. 1 ( 2018-01), p. 232-235
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 49, No. 1 ( 2018-01), p. 232-235
    Abstract: Although current guidelines advocate pretreatment with intravenous thrombolysis (IVT) in all eligible patients with acute ischemic stroke with large-vessel occlusion before mechanical thrombectomy, there are observational data questioning the efficacy of this approach. One of the main arguments in favor of IVT pretreatment is the potential for tissue-type plasminogen activator–induced successful reperfusion (SR) before the onset of endovascular procedure. Methods— We performed a systematic review and meta-analysis of randomized controlled clinical trials and observational cohorts providing rates of SR with IVT in patients with large-vessel occlusion before the initiation of mechanical thrombectomy. We also performed subgroup analyses according to study type (randomized controlled clinical trials versus observational) and according to the inclusion per protocol of patients with tandem (intracranial/extracranial) occlusions. Results— We identified 13 eligible studies (7 randomized controlled clinical trials and 6 observational cohorts), including 1561 patients with acute ischemic stroke (median National Institutes of Health Stroke Scale score, 17) with large-vessel occlusion. SR following IVT and before mechanical thrombectomy was documented in 11% (95% confidence interval, 7%–16%), with no difference among cohorts derived from randomized controlled clinical trials and observational studies. There was significant heterogeneity across included studies both in the overall analysis and among subgroups (I 2 〉 84%; P for Cochran Q, 〈 0.001). Higher tissue-type plasminogen activator–induced SR rates were documented in studies reporting the exclusion of tandem occlusions (17%; 95% confidence interval, 11%–23%) compared with the rest (7%; 95% confidence interval, 4%–11%; P for subgroup differences, 0.003). Conclusions— Pretreatment with systemic thrombolysis in patients with large-vessel occlusion eligible for mechanical thrombectomy results in SR in 1 of 10 cases, negating the need for additional endovascular reperfusion. Tandem occlusions seem to be the least responsive to IVT pretreatment.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.117.019261
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
    detail.hit.zdb_id: 1467823-8
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  • 6
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    Intravenous thrombolysis in patients with acute ischaemic stroke with history of prior ischaemic stroke within 3 months
    BMJ ; 2019
    In:  Journal of Neurology, Neurosurgery & Psychiatry
    Details
    In: Journal of Neurology, Neurosurgery & Psychiatry, BMJ
    Type of Medium: Online Resource
    ISSN: 0022-3050 , 1468-330X
    URL: Article
    DOI: 10.1136/jnnp-2019-320422
    RVK:
    XA 10000
    Language: English
    Publisher: BMJ
    Publication Date: 2019
    detail.hit.zdb_id: 1480429-3
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  • 7
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    Duration of Implantable Cardiac Monitoring and Detection of Atrial Fibrillation in Ischemic Stroke Patients: A Systematic Review and Meta-Analysis
    Korean Stroke Society ; 2019
    In:  Journal of Stroke Vol. 21, No. 3 ( 2019-09-30), p. 302-311
    Details
    In: Journal of Stroke, Korean Stroke Society, Vol. 21, No. 3 ( 2019-09-30), p. 302-311
    Type of Medium: Online Resource
    ISSN: 2287-6391 , 2287-6405
    URL: Article
    DOI: 10.5853/jos.2019.01067
    Language: English
    Publisher: Korean Stroke Society
    Publication Date: 2019
    detail.hit.zdb_id: 2814366-8
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  • 8
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    Abstract WMP62: Duration of Implantable Cardiac Monitoring and Detection of Atrial Fibrillation in Ischemic Stroke Patients: A Systematic Review and Meta-analysis
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Stroke Vol. 50, No. Suppl_1 ( 2019-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 50, No. Suppl_1 ( 2019-02)
    Abstract: Introduction: Although current guidelines indicate that the clinical benefit of prolonged cardiac monitoring for atrial fibrillation (AF) detection in ischemic stroke (IS) patients remains uncertain, clinical trials suggest that implantable cardiac monitors (ICMs) substantially increase AF detection due to prolonged monitoring duration. Methods: In the present systematic review and meta-analysis we sought to investigate the association of ICM duration with the yield of AF detection in IS patients. We also assessed whether IS subtype, individual patient characteristics and elapsed time between IS onset and CM implantation may also impact the probability of AF detection. We included studies reporting AF detection rates by ICM in IS patients with negative initial AF screening. We excluded studies reporting prolonged cardiac monitoring with devices other than ICM, not providing AF detection rates or monitoring duration and reporting overlapping data for the same population. Random-effects model was used to calculate the pooled estimates in all subgroup and univariate meta-regression analyses. Results: We included 28 studies (4531 patients; mean age:65 years; 52% men). In meta-regression analyses the proportion of AF detection by ICM was independently associated with monitoring duration (coefficient=0.015,95%CI:0.005-0.024) and mean patient age (coefficient=0.009, 95%CI:0.003-0.015). No association was detected with other patient characteristics, including IS subtype (cryptogenic vs. embolic stroke of undetermined source) or time from IS onset to CM implantation. In subgroup analyses significant differences (p 〈 0.001) in the AF detection rates were documented according to ICM duration ( 〈 6 months: 4%, 95%CI: 3%-6%; ≥6 months & ≤12 months: 20%, 95%CI: 17%-24%; 〉 12 months & ≤24 months: 26%, 95%CI: 23%-30%; 〉 24 months: 34%, 95%CI: 30%-39%). Conclusion: Extended duration of ICM monitoring appears to be the only factor that increases substantially the yield of AF detection in patients with IS and initial negative AF screening. IS subtype and individual patients characteristics, except age, are not related to the probability of AF detection.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.50.suppl_1.WMP62
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
    detail.hit.zdb_id: 1467823-8
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  • 9
    Online Resource
    Online Resource
    Advanced Neuroimaging in Stroke Patient Selection for Mechanical Thrombectomy : A Systematic Review and Meta-Analysis
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Stroke Vol. 49, No. 12 ( 2018-12), p. 3067-3070
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 49, No. 12 ( 2018-12), p. 3067-3070
    Abstract: There is clinical equipoise about the use of advanced imaging for selecting acute ischemic stroke patients eligible for mechanical thrombectomy (MT) during the first 6 hours from symptom onset. However, accumulating evidence indicates that advanced neuroimaging represents an invaluable and time-independent prognostic factor. Methods— We performed a systematic review and meta-analysis of available randomized clinical trials to evaluate the impact of patient selection with advanced neuroimaging on the 3-month: (1) functional independence (modified Rankin Scale score, 0–2), (2) favorable functional outcome (modified Rankin Scale scores, 0–1), (3) all-cause mortality, and (4) functional improvement (assessed with ordinal analysis of the modified Rankin Scale-scores). We compared patients with perfusion imaging documented penumbra to patients who did not have documented penumbra or perfusion imaging. Results— Among the 10 eligible randomized clinical trials (2227 total patients, mean age: 67 years), 5 studies reported the use of advanced imaging. Studies using advanced neuroimaging showed higher treatment effects of MT on 3-month functional independence (odds ratio [OR], 3.79; 95% CI, 2.71–5.28 versus OR, 1.89; 95% CI, 1.52–2.35; P for subgroup differences 〈 0.001), favorable functional outcome (OR, 3.16; 95% CI, 1.94–5.14 versus OR, 1.75; 95% CI, 1.30–2.34; P for subgroup differences=0.04), and functional improvement (common OR, 2.66; 95% CI, 1.95–3.63 versus common OR, 1.60; 95% CI, 1.32–1.95; P for subgroup differences=0.007) compared with studies using conventional neuroimaging. The pooled rate of successful reperfusion after MT was higher in studies with advanced neuroimaging ( P for subgroup differences=0.003). No difference in the mortality and symptomatic intracranial hemorrhage rates was found between the 2 groups. No evidence of heterogeneity was documented in all reported analyses. Conclusions— The present indirect comparisons indicate that acute ischemic stroke patient selection for MT using advanced neuroimaging appears to be associated with improved clinical outcomes. The use of advanced neuroimaging for both the selection and prediction of prognosis for MT candidates should not depend on the elapsed time from symptom onset.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.118.022540
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
    detail.hit.zdb_id: 1467823-8
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  • 10
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    Online Resource
    Prolonged cardiac monitoring for stroke prevention: A systematic review and meta-analysis of randomized-controlled clinical trials
    SAGE Publications ; 2023
    In:  European Stroke Journal Vol. 8, No. 1 ( 2023-03), p. 106-116
    Details
    In: European Stroke Journal, SAGE Publications, Vol. 8, No. 1 ( 2023-03), p. 106-116
    Abstract: Prolonged cardiac monitoring (PCM) substantially improves the detection of subclinical atrial fibrillation (AF) among patients with history of ischemic stroke (IS), leading to prompt initiation of anticoagulants. However, whether PCM may lead to IS prevention remains equivocal. Patients and methods: In this systematic review and meta-analysis, randomized-controlled clinical trials (RCTs) reporting IS rates among patients with known cardiovascular risk factors, including but not limited to history of IS, who received PCM for more than 7 days versus more conservative cardiac rhythm monitoring methods were pooled. Results: Seven RCTs were included comprising a total of 9048 patients with at least one known cardiovascular risk factor that underwent cardiac rhythm monitoring. PCM was associated with reduction of IS occurrence compared to conventional monitoring (Risk Ratio: 0.76; 95% CI: 0.59–0.96; I 2  = 0%). This association was also significant in the subgroup of RCTs investigating implantable cardiac monitoring (Risk Ratio: 0.75; 95% CI: 0.58–0.97; I 2  = 0%). However, when RCTs assessing PCM in both primary and secondary prevention settings were excluded or when RCTs investigating PCM with a duration of 7 days or less were included, the association between PCM and reduction of IS did not retain its statistical significance. Regarding the secondary outcomes, PCM was related to higher likelihood for AF detection and anticoagulant initiation. No association was documented between PCM and IS/transient ischemic attack occurrence, all-cause mortality, intracranial hemorrhage, or major bleeding. Conclusion: PCM may represent an effective stroke prevention strategy in selected patients. Additional RCTs are warranted to validate the robustness of the reported associations.
    Type of Medium: Online Resource
    ISSN: 2396-9873 , 2396-9881
    URL: Article
    DOI: 10.1177/23969873221139410
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2023
    detail.hit.zdb_id: 2851287-X
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