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  • 1
    Online Resource
    Online Resource
    Endovascular Treatment for Acute Ischemic Stroke With or Without General Anesthesia: A Matched Comparison
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Stroke Vol. 53, No. 5 ( 2022-05), p. 1520-1529
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 53, No. 5 ( 2022-05), p. 1520-1529
    Abstract: Endovascular treatment in large artery occlusion stroke reduces disability. However, the impact of anesthesia type on clinical outcomes remains uncertain. Methods: We compared consecutive patients in the Swiss Stroke Registry with anterior circulation stroke receiving endovascular treatment with or without general anesthesia (GA). The primary outcome was disability on the modified Rankin Scale after 3 months, analyzed with ordered logistic regression. Secondary outcomes included dependency or death (modified Rankin Scale score ≥ 3), National Institutes of Health Stroke Scale after 24 hours, symptomatic intracranial hemorrhage with ≥ 4 points worsening on National Institutes of Health Stroke Scale within 7 days, and mortality. Coarsened exact matching and propensity score matching were performed to adjust for indication bias. Results: One thousand two hundred eighty-four patients (GA: n=851, non-GA: n=433) from 8 Stroke Centers were included. Patients treated with GA had higher modified Rankin Scale scores after 3 months than patients treated without GA, in the unmatched (odds ratio [OR], 1.75 [1.42–2.16] ; P 〈 0.001), the coarsened exact matching (n=332–524, using multiple imputations of missing values; OR, 1.60 [1.08–2.36]; P =0.020), and the propensity score matching analysis (n=568; OR, 1.61 [1.20–2.15]; P =0.001). In the coarsened exact matching analysis, there were no significant differences in National Institutes of Health Stroke Scale after 1 day (estimated coefficient 2.61 [0.59–4.64]), symptomatic intracranial hemorrhage (OR, 1.06 [0.30–3.75] ), dependency or death (OR, 1.42 [0.91–2.23]), or mortality (OR, 1.65 [0.94–2.89] ). In the propensity score matching analysis, National Institutes of Health Stroke Scale after 24 hours (estimated coefficient, 3.40 [1.76–5.04]), dependency or death (OR, 1.49 [1.07–2.07] ), and mortality (OR, 1.65 [1.11–2.45]) were higher in the GA group, whereas symptomatic intracranial hemorrhage did not differ significantly (OR, 1.77 [0.73–4.29] ). Conclusions: This large study showed worse functional outcome after endovascular treatment of anterior circulation stroke with GA than without GA in a real-world setting. This finding appears to be independent of known differences in patient characteristics between groups.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.121.034934
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
    detail.hit.zdb_id: 1467823-8
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  • 2
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    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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  • 3
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    Effect of admission time on provision of acute stroke treatment at stroke units and stroke centers—An analysis of the Swiss Stroke Registry
    SAGE Publications ; 2022
    In:  European Stroke Journal Vol. 7, No. 2 ( 2022-06), p. 117-125
    Details
    In: European Stroke Journal, SAGE Publications, Vol. 7, No. 2 ( 2022-06), p. 117-125
    Abstract: Rapid treatment of acute ischemic stroke (AIS) depends on sufficient staffing which differs between Stroke Centers and Stroke Units in Switzerland. We studied the effect of admission time on performance measures of AIS treatment and related temporal trends over time. Patients and methods: We compared treatment rates, door-to-image-time, door-to-needle-time, and door-to-groin-puncture-time in stroke patients admitted during office hours (Monday–Friday 8:00–17:59) and non-office hours at all certified Stroke Centers and Stroke Units in Switzerland, as well as secular trends thereof between 2014 and 2019, using data from the Swiss Stroke Registry. Secondary outcomes were modified Rankin Scale and mortality at 3 months. Results: Data were eligible for analysis in 31,788 (90.2%) of 35,261 patients. Treatment rates for IVT/EVT were higher during non-office hours compared with office hours in Stroke Centers (40.8 vs 36.5%) and Stroke Units (21.8 vs 18.5%). Door-to-image-time and door-to-needle-time increased significantly during non-office hours. Median (IQR) door-to-groin-puncture-time at Stroke Centers was longer during non-office hours compared to office hours (84 (59–116) vs 95 (66–130) minutes). Admission during non-office hours was independently associated with worse functional outcome (1.11 [95%CI: 1.04–1.18]) and increased mortality (1.13 [95%CI: 1.01–1.27] ). From 2014 to 2019, median door-to-groin-puncture-time improved and the treatment rate for wake-up strokes increased. Discussion and Conclusion: Despite differences in staffing, patient admission during non-office hours delayed IVT to a similar, modest degree at Stroke Centers and Stroke Units. A larger delay of EVT was observed during non-office hours, but Stroke Centers sped up delivery of EVT over time. Patients admitted during non-office hours had worse functional outcomes, which was not explained by treatment delays.
    Type of Medium: Online Resource
    ISSN: 2396-9873 , 2396-9881
    URL: Article
    DOI: 10.1177/23969873221094408
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2022
    detail.hit.zdb_id: 2851287-X
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  • 4
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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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  • 5
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    Safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data
    BMJ ; 2021
    In:  Journal of NeuroInterventional Surgery Vol. 13, No. 12 ( 2021-12), p. 1073-1080
    Details
    In: Journal of NeuroInterventional Surgery, BMJ, Vol. 13, No. 12 ( 2021-12), p. 1073-1080
    Abstract: Achieving the best possible reperfusion is a key determinant of clinical outcome after mechanical thrombectomy (MT). However, data on the safety and efficacy of intra-arterial (IA) fibrinolytics as an adjunct to MT with the intention to improve reperfusion are sparse. Methods We performed a PROSPERO-registered (CRD42020149124) systematic review and meta-analysis accessing MEDLINE, PubMed, and Embase from January 1, 2000 to January 1, 2020. A random-effect estimate (Mantel-Haenszel) was computed and summary OR with 95% CI were used as a measure of added IA fibrinolytics versus control on the risk of symptomatic intracranial hemorrhage (sICH) and secondary endpoints (modified Rankin Scale ≤2, mortality at 90 days). Results The search identified six observational cohort studies and three observational datasets of MT randomized-controlled trial data reporting on IA fibrinolytics with MT as compared with MT alone, including 2797 patients (405 with additional IA fibrinolytics (100 urokinase (uPA), 305 tissue plasminogen activator (tPA)) and 2392 patients without IA fibrinolytics). Of 405 MT patients treated with additional IA fibrinolytics, 209 (51.6%) received prior intravenous tPA. We did not observe an increased risk of sICH after administration of IA fibrinolytics as adjunct to MT (OR 1.06, 95% CI 0.64 to 1.76), nor excess mortality (0.81, 95% CI 0.60 to 1.08). Although the mode of reporting was heterogeneous, some studies observed improved reperfusion after IA fibrinolytics. Conclusion The quality of evidence regarding peri-interventional administration of IA fibrinolytics in MT is low and limited to observational data. In highly selected patients, no increase in sICH was observed, but there is large uncertainty.
    Type of Medium: Online Resource
    ISSN: 1759-8478 , 1759-8486
    URL: Article
    DOI: 10.1136/neurintsurg-2020-016680
    Language: English
    Publisher: BMJ
    Publication Date: 2021
    detail.hit.zdb_id: 2506028-4
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  • 6
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    Impact of pre-stroke dependency on outcome after endovascular therapy in acute ischemic stroke
    Springer Science and Business Media LLC ; 2021
    In:  Journal of Neurology Vol. 268, No. 2 ( 2021-02), p. 541-548
    Details
    In: Journal of Neurology, Springer Science and Business Media LLC, Vol. 268, No. 2 ( 2021-02), p. 541-548
    Abstract: Current demographic changes indicate that more people will be care-dependent due to increasing life expectancy. Little is known about impact of preexisting dependency on stroke outcome after endovascular treatment (EVT). Methods We compared prospectively collected baseline and outcome data of previously dependent vs. independent stroke patients (prestroke modified Rankin Scale score of 3–5 vs. 0–2) treated with EVT. Outcome measures were favorable 3-month outcome (mRS ≤ 3 for previously dependent and mRS ≤ 2 for independent patients, respectively), death and symptomatic intracranial hemorrhage (sICH). Results Among 1247 patients, 84 (6.7%) were dependent before stroke. They were older (81 vs. 72 years of age), more often female (61.9% vs. 46%), had a higher stroke severity at baseline (NIHSS 18 vs. 15 points), more often history of previous stroke (32.9% vs. 9.1%) and more vascular risk factors than independent patients. Favorable outcome and mortality were to the disadvantage of independent patients (26.2% vs. 44.4% and 46.4% vs. 25.5%, respectively), whereas sICH was comparable in both cohorts (4.9% vs. 5%). However, preexisting dependency was not associated with clinical outcome and mortality after adjusting for outcome predictors (OR 1.076, 95% CI 0.612–1.891; p  = 0.799 and OR 1.267, 95% CI 0.758–2.119; p  = 0.367, respectively). Conclusion Our study underscores the need for careful selection of care-dependent stroke patients when considering EVT, given a less favorable outcome observed in this cohort. Nonetheless, EVT should not systematically be withheld in patients with preexisting disability, since prior dependency does not significantly influence outcome.
    Type of Medium: Online Resource
    ISSN: 0340-5354 , 1432-1459
    URL: Article
    DOI: 10.1007/s00415-020-10172-3
    RVK:
    XA 10000
    Language: English
    Publisher: Springer Science and Business Media LLC
    Publication Date: 2021
    detail.hit.zdb_id: 1421299-7
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  • 7
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    Association of initial imaging modality and futile recanalization after thrombectomy
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Neurology Vol. 95, No. 17 ( 2020-10-27), p. e2331-e2342
    Details
    In: Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 95, No. 17 ( 2020-10-27), p. e2331-e2342
    Abstract: To test the hypothesis that selection by initial imaging modality (MRI vs CT) is associated with rate of futile recanalizations (FRs) after mechanical thrombectomy (MT), we assessed this association in a multicenter, retrospective observational registry (BEYOND-SWIFT [Registry for Evaluating Outcome of Acute Ischemic Stroke Patients Treated With Mechanical Thrombectomy], NCT03496064 ). Methods In 2,011 patients (49.7% female, median age 73 years [61–81]) included between 2009 and 2017, we performed univariate and multivariate analyses regarding the occurrence of FR. FRs were defined as 90-day modified Rankin Scale (mRS) score 4–6 despite successful recanalization in patients selected by MRI (n = 690) and CT (n = 1,321) with a sensitivity analysis considering only patients with mRS 5–6 as futile. Results MRI as compared to CT resulted in similar rates of subsequent MT (adjusted odds ratio [aOR] 1.048, 95% confidence interval [CI] 0.677–1.624). Rates of FR were as follows: 571/1,489 (38%) FR mRS 4–6 including 393/1,489 (26%) FR mRS 5–6. CT-based selection was associated with increased rates of FRs compared to MRI (44% [41%–47%] vs 29% [25%–32%] , p 〈 0.001; aOR 1.77 [95% CI 1.25–2.51]). These findings were robust in sensitivity analysis. MRI-selected patients had a delay of approximately 30 minutes in workflow metrics in real-world university comprehensive stroke centers. However, functional outcome and mortality were more favorable in patients selected by MRI compared to patients selected with CT. Conclusions CT selection for MT was associated with an increased risk of FRs as compared to MRI selection. Efforts are needed to shorten workflow delays in MRI patients. Further research is needed to clarify the role of the initial imaging modality on FR occurrence and to develop a reliable FR prediction algorithm.
    Type of Medium: Online Resource
    ISSN: 0028-3878 , 1526-632X
    URL: Article
    DOI: 10.1212/WNL.0000000000010614
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
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  • 8
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    Stroke severity in patients with preceding direct oral anticoagulant therapy as compared to vitamin K antagonists
    Springer Science and Business Media LLC ; 2019
    In:  Journal of Neurology Vol. 266, No. 9 ( 2019-9), p. 2263-2272
    Details
    In: Journal of Neurology, Springer Science and Business Media LLC, Vol. 266, No. 9 ( 2019-9), p. 2263-2272
    Type of Medium: Online Resource
    ISSN: 0340-5354 , 1432-1459
    URL: Article
    DOI: 10.1007/s00415-019-09412-y
    RVK:
    XA 10000
    Language: English
    Publisher: Springer Science and Business Media LLC
    Publication Date: 2019
    detail.hit.zdb_id: 1421299-7
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  • 9
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    Association of Chronic Covert Cerebral Infarctions and White Matter Hyperintensities With Atrial Fibrillation Detection on Post‐Stroke Cardiac Rhythm Monitoring: A Cohort Study
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Journal of the American Heart Association Vol. 11, No. 24 ( 2022-12-20)
    Details
    In: Journal of the American Heart Association, Ovid Technologies (Wolters Kluwer Health), Vol. 11, No. 24 ( 2022-12-20)
    Abstract: This study was conducted to explore the association of different phenotypes, count, and location of chronic covert brain infarctions (CBIs) with detection of atrial fibrillation (AF) on prolonged post‐stroke cardiac rhythm monitoring (PCM). Methods and Results We conducted a cohort single‐center study of consecutive first‐ever ischemic stroke or transient ischemic attack patients undergoing PCM between January 2015 and December 2017. We blindly rated CBI phenotypes according to established definitions and white matter hyperintensities (WMHs) according to the age‐related white matter changes rating scale. We used (multiple) regression models to assess the association of the imaging biomarkers and incident AF on PCM. A total of 795 patients (median [interquartile range]) aged 69 (57–78) years, 41% women, median National Institutes of Health Stroke Scale score 2 (0–5), median PCM duration 14 (7–14) days, and AF detection in 61 patients (7.7%) were included. On univariate analysis, WMHs (per point odds ratio, 1.35 [95% CI, 1.03–1.78] ) but not CBIs (odds ratio, 0.90 [95% CI, 0.52–1.56]) were associated with AF detection. Neither CBI phenotype, count, nor location were associated with AF detection. After adjustment for age, hypertension, and stroke severity, neither increasing WMHs (per point adjusted odds ratio, 0.85 [95% CI, 0.60–1.20] ) nor CBIs (adjusted odds ratio, 0.60 [95% CI, 0.33–1.09] ) were independently associated with AF detection. Conclusions Although WMHs and CBIs represent surrogate biomarkers of vascular risk factors, neither WMHs nor CBIs, including their phenotypes, count, and location, were independently associated with AF detection on PCM. In patients with manifest ischemic stroke or transient ischemic attack, the presence of imaging biomarkers of chronic ischemic injury does not seem promising to further refine prediction tools for AF detection on PCM.
    Type of Medium: Online Resource
    ISSN: 2047-9980
    URL: Article
    DOI: 10.1161/JAHA.122.026962
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
    detail.hit.zdb_id: 2653953-6
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  • 10
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    Multivariable Prediction Model for Futile Recanalization Therapies in Patients With Acute Ischemic Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Neurology Vol. 99, No. 10 ( 2022-09-6), p. e1009-e1018
    Details
    In: Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 99, No. 10 ( 2022-09-6), p. e1009-e1018
    Abstract: Very poor outcome despite IV thrombolysis (IVT) and mechanical thrombectomy (MT) occurs in approximately 1 of 4 patients with ischemic stroke and is associated with a high logistic and economic burden. We aimed to develop and validate a multivariable prognostic model to identify futile recanalization therapies (FRTs) in patients undergoing those therapies. Methods Patients from a prospectively collected observational registry of a single academic stroke center treated with MT and/or IVT were included. The data set was split into a training (N = 1,808, 80%) and internal validation (N = 453, 20%) cohort. We used gradient boosted decision tree machine learning models after k-nearest neighbor imputation of 32 variables available at admission to predict FRT defined as modified Rankin scale 5–6 at 3 months. We report feature importance, ability for discrimination, calibration, and decision curve analysis. Results A total of 2,261 patients with a median (interquartile range) age of 75 years (64–83 years), 46% female, median NIH Stroke Scale 9 (4–17), 34% IVT alone, 41% MT alone, and 25% bridging were included. Overall, 539 (24%) had FRT, more often in MT alone (34%) as compared with IVT alone (11%). Feature importance identified clinical variables (stroke severity, age, active cancer, prestroke disability), laboratory values (glucose, C-reactive protein, creatinine), imaging biomarkers (white matter hyperintensities), and onset-to-admission time as the most important predictors. The final model was discriminatory for predicting 3-month FRT (area under the curve 0.87, 95% CI 0.87–0.88) and had good calibration (Brier 0.12, 0.11–0.12). Overall performance was moderate (F1-score 0.63 ± 0.004), and decision curve analyses suggested higher mean net benefit at lower thresholds of treatment (up to 0.8). Conclusions This FRT prediction model can help inform shared decision making and identify the most relevant features in the emergency setting. Although it might be particularly useful in low resource healthcare settings, incorporation of further multifaceted variables is necessary to further increase the predictive performance.
    Type of Medium: Online Resource
    ISSN: 0028-3878 , 1526-632X
    URL: Article
    DOI: 10.1212/WNL.0000000000200815
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
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