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  • 1
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    Endovascular treatment for basilar artery occlusion: A systematic review and meta‐analysis
    Wiley ; 2021
    In:  European Journal of Neurology Vol. 28, No. 6 ( 2021-06), p. 2106-2110
    Details
    In: European Journal of Neurology, Wiley, Vol. 28, No. 6 ( 2021-06), p. 2106-2110
    Abstract: Independent randomized controlled clinical trials (RCTs) have provided robust evidence for endovascular treatment (EVT) as the standard of care treatment for acute large vessel occlusions in the anterior circulation. We examined available studies specific to posterior cerebral circulation ischemic strokes to see if any conclusions can be drawn regarding EVT options. Methods We performed a systematic literature search to identify studies evaluating the safety and efficacy of EVT versus standard medical treatment for patients with acute basilar artery occlusion (BAO). We extracted data for outcomes of interest and presented associations between the two groups with the use of risk ratios (RRs) or odds ratios (ORs), with corresponding 95% confidence intervals (CIs). We used a random‐effects model to pool the effect estimates. Results We identified five studies (two RCTs, three observational cohorts) including a total of 1098 patients. Patients receiving EVT had a higher risk of symptomatic intracranial hemorrhage (sICH) compared to those receiving non‐interventional medical management (RR 5.42, 95% CI 2.74–10.71). Nonsignificant trends towards modified Rankin Scale (mRS) scores 0–2 (RR 1.02, 95% CI 0.74–1.41), mRS scores 0–3 (RR = 0.97, 95% CI 0.64–1.47), overall functional improvement (OR 0.93, 95% CI 0.57–1.51), and all‐cause mortality (RR 1.03, 95% CI 0.78–1.35) at 3 months were seen. Conclusion Although EVT increases the probability of sICH, the available data do not exclude the possibility of improved functional outcomes over standard therapy. As larger studies are challenged by the perceived lack of equipoise in this vulnerable patient population, results of ongoing RCTs are expected to provide substantial input for future meta‐analyses.
    Type of Medium: Online Resource
    ISSN: 1351-5101 , 1468-1331
    URL: Issue
    URL: Article
    DOI: 10.1111/ene.v28.6
    DOI: 10.1111/ene.14751
    Language: English
    Publisher: Wiley
    Publication Date: 2021
    detail.hit.zdb_id: 2020241-6
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  • 2
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    Intravenous Thrombolysis for Ischemic Stroke Patients on Dual Antiplatelets
    Wiley ; 2018
    In:  Annals of Neurology Vol. 84, No. 1 ( 2018-07), p. 89-97
    Details
    In: Annals of Neurology, Wiley, Vol. 84, No. 1 ( 2018-07), p. 89-97
    Abstract: We assessed the outcomes of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients on dual antiplatelet therapy prior to stroke onset. Methods We analyzed prospectively collected data from the Safe Implementation of Treatments in Stroke (SITS) International Stroke Thrombolysis Register on consecutive IVT‐treated AIS patients during a 7‐year period (2010–2017). In propensity score matched groups of patients with dual antiplatelet pretreatment and no antiplatelet pretreatment, we compared: (1) symptomatic intracerebral hemorrhage (SICH), according to SITS Monitoring Study (MOST), European Cooperative Acute Stroke Study (ECASS) II, and National Institute of Neurological Disorders and Stroke (NINDS) definitions; (2) 3‐month mortality; (3) 3‐month favorable functional outcome (FFO; modified Rankin Scale [mRS] scores = 0–1); (4) 3‐month functional independence (FI; mRS scores = 0–2); and (5) distribution of the 3‐month mRS scores. Dual antiplatelet pretreatment was defined as all possible combinations among aspirin, clopidogrel, dipyridamole, and any other antiplatelet. Results Propensity score matching resulted in 2 groups of 1,043 patients each, balanced for all baseline characteristics. In the propensity score matched analysis, the 2 groups had comparable ( p   〉  0.017 using Bonferroni correction for multiple comparisons) SICH rates according to SITS‐MOST (2.9% vs 1.5%, 95% confidence interval [CI] = −0.03 to −0.01), ECASS II (5.2% vs 4.4%, 95% CI = −0.03 to 0.01), and NINDS (7.7% vs 6.6%, 95% CI = −0.03 to 0.01) definitions. No differences in the 3‐month mortality (17.9% vs 16.6%, 95% CI = −0.05 to 0.02), FFO (45.6% vs 46.0%, 95% CI = −0.04 to 0.05), FI (59.2% vs 60.7%, 95% CI = −0.03 to 0.06), or distribution in 3‐month mRS scores (2 [1–4] vs 2 [0–4], 95% CI = −0.29 to 0.09) were documented between the 2 groups. Interpretation Given that patients on dual antiplatelet pretreatment have similar SICH, 3‐month mortality rates, and functional outcomes compared to patients with no antiplatelet pretreatment, dual antiplatelet pretreatment history should not be used as a reason to withhold IVT in otherwise eligible AIS patients. Ann Neurol 2018;83:89–97
    Type of Medium: Online Resource
    ISSN: 0364-5134 , 1531-8249
    URL: Issue
    URL: Article
    DOI: 10.1002/ana.v84.1
    DOI: 10.1002/ana.25269
    Language: English
    Publisher: Wiley
    Publication Date: 2018
    detail.hit.zdb_id: 2037912-2
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  • 3
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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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  • 4
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    Novel oral anticoagulants for the secondary prevention of cerebral ischemia: a network meta-analysis
    SAGE Publications ; 2016
    In:  Therapeutic Advances in Neurological Disorders Vol. 9, No. 5 ( 2016-09), p. 359-368
    Details
    In: Therapeutic Advances in Neurological Disorders, SAGE Publications, Vol. 9, No. 5 ( 2016-09), p. 359-368
    Abstract: Novel oral anticoagulants (NOACs) have shown to be both safe and effective for ischemic stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). We conducted a network meta-analysis (NMA) using published data from secondary prevention subgroups of different phase III randomized clinical trials (RCTs) comparing individual NOACs with warfarin. Methods: Eligible studies were identified by searching MEDLINE and SCOPUS and the Cochrane Central Register of Controlled Trials databases. First, we conducted a pairwise meta-analysis for each pairwise comparison, and then we performed NMA to combine direct and indirect evidence for any given pair of treatments. The comparative effects of all NOACs against warfarin were ranked with the surface under the cumulative ranking (SUCRA) curve for each outcome. Results: We identified four RCTs (including 15,240 patients) comparing individual NOACs (apixaban, dabigatran, rivaroxaban) with warfarin. Using indirect evidence, dabigatran was related to a significantly lower risk of hemorrhagic stroke compared with rivaroxaban [risk ratio (RR) 0.28; 95% confidence interval (CI) 0.11–0.75], while rivaroxaban was associated with a significantly lower risk of major gastrointestinal bleeding compared with dabigatran (RR 0.14; 95% CI 0.03–0.74). We also performed clustered ranking plot for the primary efficacy and safety endpoints to identify the treatment with the probably best benefit-to-risk ratio profile. Conclusions: The three NOACs showed differences in terms of safety and efficacy for secondary stroke prevention in NVAF. Our findings can serve only as hypothesis generation and require independent confirmation in head-to-head RCTs, owing to the sparse available evidence and increased uncertainty in both indirect effect estimates and ranking of treatments.
    Type of Medium: Online Resource
    ISSN: 1756-2864 , 1756-2864
    URL: Article
    DOI: 10.1177/1756285616659411
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2016
    detail.hit.zdb_id: 2442245-9
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  • 5
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    Abstract 130: Is Intravenous Thrombolysis Far From Obsolete in the Era of Endovascular Thrombectomy? A Hint From a Meta-analysis of Randomized Clinical Trials
    Ovid Technologies (Wolters Kluwer Health) ; 2017
    In:  Stroke Vol. 48, No. suppl_1 ( 2017-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 48, No. suppl_1 ( 2017-02)
    Abstract: Background & Purpose: Current AHA recommendations advocate that pretreatment with intravenous thrombolysis (IVT) should first be offered to all eligible acute ischemic stroke (AIS) patients with emergent large vessel occlusion (ELVO) before an endovascular thrombectomy (ET) procedure. Nevertheless, recent single-center observational studies question the utility of IVT pretreatment in ELVO patients eligible for systemic thrombolysis and advocate ET monotherapy. We sought to evaluate the comparative efficacy between ET and bridging therapy (IVT & ET) in AIS due to ELVO. Methods: We performed mixed-effects subgroup analyses, according to IVT pretreatment status of both functional independence [modified Rankin Scale (mRS) of 0-2)] and death/dependency (mRS of 5-6) at 90 days using available RCTs that evaluated the safety and efficacy of ET with stent-retrievers in comparison to standard therapy. We additionally performed an ordinal logistic regression analysis of individual patient data on the distribution of 3-month mRS scores (shift analysis) between the two groups. Results: We identified 7 eligible RCTs including 1764 ELVO patients (53% men), and 108 patients randomized to ET without IVT pretreatment. Patients receiving bridging therapy (BT) had lower rates (p=0.041) of 90-day death/dependency (19%, 95%CI: 14%-25%) compared to patients receiving only ET (31%, 95%CI: 21%-43%; Figure). Similarly, shift-analysis favored a trend for BT over ET in terms of better 90-day functional outcome (common OR=0.78, 95%CI: 0.53-1.10; p=0.155). Conclusion: Our findings indicate that pretreatment with IVT prior ET in ELVO patients may be associated with lower rates of three-month death/dependency and a trend towards more favorable functional outcomes. Until the results from head-to-head RCTs comparing BT to ET monotherapy become available, our findings support AHA guidelines recommending delivery of tPA to appropriate ELVO candidates undergoing ET.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.48.suppl_1.130
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2017
    detail.hit.zdb_id: 1467823-8
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  • 6
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    Abstract 105: Percutaneous Patent Foramen Ovale Closure for the Secondary Prevention of Cryptogenic Cerebral Ischemia: A Network 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: Current guidelines report no benefit for patent foramen ovale (PFO) closure compared to medical treatment in patients with cryptogenic ischemic stroke (IS) or transient ischemic attack (TIA). Two recent randomized-controlled clinical trials (RCTs) have challenged these recommendations. We performed a systematic review and network meta-analysis (NMA) of RCTs to estimate the safety and efficacy of closure compared to medical treatment, and to compare available devices. Methods: We conducted pairwise meta-analyses for closure vs medical therapy, and for each device vs medical therapy. We performed subgroup analyses for the outcome of IS recurrence according to shunt size and atrial septal aneurysm (ASA) presence. For all devices we calculated the pooled rates of effective closure and serious peri-procedural complications. We used NMA to combine direct and indirect evidence for any given pair of treatments. Results: Literature search identified 6 eligible studies. PFO occlusion was associated with reduced risk of recurrent IS (RR=0.39, 95%CI:0.18-0.88) and IS/TIA (RR=0.66, 95%CI:0.46-0.94), but with increased risk of new-onset atrial fibrillation (AF; RR=4.73, 95%CI:2.09-10.71) compared to medical treatment. We detected no differences on the risk of recurrent IS according to PFO size (p=0.83) or ASA presence (p=0.39). Amplatzer and GORE HELEX/CARDIOFORM occluders were associated with more effective IS/TIA prevention (Panels A-B) and lower AF risk compared to STARFlex Septal Occluder (Panel C). Conclusions: PFO closure is related with reduced risk of recurrent IS/TIA and with increased risk of new-onset AF. These associations are independent of PFO size and ASA presence.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.49.suppl_1.105
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
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  • 7
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    Abstract P82: The Impact of SARS-COV-2 on Stroke Epidemiology and Care: A Meta-Analysis
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Stroke Vol. 52, No. Suppl_1 ( 2021-03)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 52, No. Suppl_1 ( 2021-03)
    Abstract: Background: Emerging data indicates an increased risk for cerebrovascular events with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and highlights the potential impact of coronavirus disease (COVID-19) on the management and outcomes of acute stroke. We conducted a systematic review and meta-analysis to evaluate the aforementioned considerations. Methods: We performed a meta-analysis of observational cohort studies reporting on the occurrence and/or outcomes of patients with cerebrovascular events in association with their SARS-CoV-2 infection status. We used a random-effects model. Summary estimates were reported as odds ratios (ORs) and corresponding 95% confidence intervals (95%CI). Results: We identified 16 cohort studies including 44,004 patients. Among patients with SARS-CoV-2, 1.3% (95%CI: 0.9-1.8%; I 2 =88%) were hospitalized for cerebrovascular events, 1.2% (95%CI: 0.8-1.5%; I 2 =85%) for ischemic stroke, and 0.2% (95%CI: 0.1-0.4%; I 2 =69%) for hemorrhagic stroke. Compared to non-infected contemporary or historical controls, patients with SARS-CoV-2 infection had increased odds of ischemic stroke (OR=3.58, 95%CI: 1.43-8.92; I 2 =43%) and cryptogenic stroke (OR=3.98, 95%CI: 1.62-9.77; I 2 =0%). Odds for in-hospital mortality were higher among SARS-CoV-2 stroke patients compared to non-infected contemporary or historical stroke patients (OR=5.60, 95%CI: 3.19-9.80; I 2 =45%). SARS-CoV-2 infection status was not associated to the likelihood of receiving intravenous thrombolysis (OR=1.42, 95%CI: 0.65-3.10; I 2 =0%) or endovascular thrombectomy (OR=0.78, 95%CI: 0.35-1.74; I 2 =0%) among hospitalized ischemic stroke patients during the COVID-19 pandemic. Diabetes mellitus was found to be more prevalent among SARS-CoV-2 stroke patients compared to non-infected contemporary or historical controls (OR=1.39, 95%CI: 1.04-1.86; I 2 =0%). Conclusion: SARS-CoV-2 appears to be associated with an increased risk of ischemic stroke, particularly the cryptogenic subtype. SARS-CoV-2 infection in stroke substantially increases the mortality risk.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.52.suppl_1.P82
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
    detail.hit.zdb_id: 1467823-8
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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
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    Abstract TP199: Incidence, Characteristics and Outcomes in Patients With Embolic Stroke of Undetermined Source: A Population-based Study
    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: Embolic stroke of undetermined source (ESUS) represents a subgroup of cryptogenic ischemic stroke (CS) distinguished by high probability of an underlying embolic mechanism. There are scarce population-based data regarding the incidence, characteristics and outcomes of ESUS. Methods: Consecutive patients included with first-ever ischemic stroke of undetermined cause in the previously published population-based Evros Stroke Registry were further subdivided into ESUS and non-ESUS CS. Crude and adjusted [according to the European Standard Population (ESP), WHO and Segi population] incidence rates (IR) for ESUS and non-ESUS CS were calculated. Baseline characteristics, admission stroke severity (assessed using NIHSS-score), stroke recurrence and functional outcomes [determined by modified Rankin Scale (mRS) scores] , were recorded during the 1-year follow-up period. Results: We identified 21 and 242 cases with ESUS (8% of CS) and non-ESUS CS. The crude and ESP-adjusted IR for ESUS were 17.5 (95%CI: 10-25) and 16.6 (95%CI: 10-24) per 100,000 person-years. Patients with ESUS were younger [median age 68 years (IQR:61-75) vs. 79 years (IQR:73-83); p 〈 0.001] and had lower median admission NIHSS-scores [4 points (IQR:2-8) vs. 8 points (IQR:5-16); p 〈 0.001]. Functional outcomes were more favorable in ESUS at 28 [median mRS-score: 2 (IQR:1-3) vs. 4 (IQR:3-6)] , 90 [median mRS-score: 1 (IQR:0-2) vs. 4 (IQR:2-6)] and 365 days [median mRS-score: 1 (IQR:0-2) vs. 5 (IQR:2-6)] . ESUS was independently (p=0.033) associated with lower admission NIHSS-scores (unstandardized linear regression coefficient: -13.34;95%CI: -23.34, -3.35) on multiple linear regression models. ESUS was not related to 1-year stroke recurrence (HR: 0.22, 95%CI: 0.01-4.06), mortality (HR: 0.25, 95%CI: 0.02-4.36) and functional improvement (1-point shift in mRS-scores; cOR: 1.47, 95%CI: 0.59-3.70) on multivariable analyses. Conclusions: ESUS cases represented 8% of CS patients in this population-based study. Despite the fact that ESUS was independently related to lower admission stroke severity, there was no association of ESUS with long-term outcomes.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.50.suppl_1.TP199
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 10
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    Abstract 106: Safety and Efficacy of Sonothrombolysis in Acute Ischemic Stroke Patients With Large Vessel Occlusion: International Collaborative Individual Patient Data Meta-Analysis
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Stroke Vol. 51, No. Suppl_1 ( 2020-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 51, No. Suppl_1 ( 2020-02)
    Abstract: Introduction: Conflicting evidence has been published regarding the safety and efficacy of ultrasound-enhanced thrombolysis (sonothrombolysis) in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). Methods: We conducted an individual participant data meta-analysis of available randomized controlled trials (RCTs) comparing sonothrombolysis with or without addition of microspheres (treatment group) to intravenous thrombolysis alone (control group) in AIS patients with LVO. Results: We included 6 in total RCTs that enrolled 1077 AIS patients. A total of 138 and 134 confirmed LVO patients were randomized to treatment and control groups respectively (median age 68 years, 58% men, median baseline NIHSS score 16). Patients randomized to sonothrombolysis had increased odds of complete recanalization compared to patients receiving intravenous thrombolysis alone (40.3% vs. 22.4%; OR=2.30, 95%CI: 1.05-5.02; adjusted OR=2.33, 95%CI: 1.02-5.34). They also tended to have increased odds of any (complete or partial recanalization (66.4% vs. 53.0%; OR=1.78, 95%CI: 0.95-3.33; adjusted OR=1.85, 95%CI: 0.97-3.53). The likelihood of symptomatic intracranial hemorrhage did not differ between the two groups (7.3% vs. 3.7%, OR=2.52, 95%CI: 0.77-8.29; adjusted OR=2.55, 95%CI: 0.76-8.52). No differences in the likelihood of asymptomatic intracranial hemorrhage (adjusted OR: 1.30, 95%CI: 0.38-4.39), three-month mortality (adjusted OR: 1.23, 95%CI: 0.25-6.05), three-month favorable functional outcome (mRS-scores of 0-1; adjusted OR: 1.43, 95%CI: 0.64-3.19) and three-month functional independence (mRS-scores of 0-2; adjusted OR: 1.43, 95%CI: 0.77-2.64) were documented. Conclusion: Sonothrombolysis was associated with a two-fold increase in the odds of complete recanalization compared to intravenous thrombolysis alone in AIS patients with LVOs. Further study of the safety and efficacy of sonothrombolysis is warranted.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.51.suppl_1.106
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
    detail.hit.zdb_id: 1467823-8
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