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  • 1
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    Online Resource
    Antiplatelet Therapy After Spontaneous Intracerebral Hemorrhage and Functional Outcomes
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Stroke Vol. 50, No. 11 ( 2019-11), p. 3057-3063
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 50, No. 11 ( 2019-11), p. 3057-3063
    Abstract: Observational data suggest that antiplatelet therapy after intracerebral hemorrhage (ICH) alleviates thromboembolic risk without increasing the risk of recurrent ICH. Given the paucity of data on the relationship between antiplatelet therapy after ICH and functional outcomes, we aimed to study this association in a multicenter cohort. Methods— We meta-analyzed data from (1) the Massachusetts General Hospital ICH registry (n=1854), (2) the Virtual International Stroke Trials Archive database (n=762), and (3) the Yale stroke registry (n=185). Our exposure was antiplatelet therapy after ICH, which was modeled as a time-varying covariate. Our primary outcomes were all-cause mortality and a composite of major disability or death (modified Rankin Scale score 4–6). We used Cox proportional regression analyses to estimate the hazard ratio of death or poor functional outcome as a function of antiplatelet therapy and random-effects meta-analysis to pool the estimated HRs across studies. Additional analyses stratified by hematoma location (lobar and deep ICH) were performed. Results— We included a total of 2801 ICH patients, of whom 288 (10.3%) were started on antiplatelet medications after ICH. Median times to antiplatelet therapy ranged from 7 to 39 days. Antiplatelet therapy after ICH was not associated with mortality (hazard ratio, 0.85; 95% CI, 0.66–1.09), or death or major disability (hazard ratio, 0.83; 95% CI, 0.59–1.16) compared with patients not started on antiplatelet therapy. Similar results were obtained in additional analyses stratified by hematoma location. Conclusions— Antiplatelet therapy after ICH appeared safe and was not associated with all-cause mortality or functional outcome, regardless of hematoma location. Randomized clinical trials are needed to determine the effects and harms of antiplatelet therapy after ICH.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.119.025972
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 2
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    Rates of Spinal Cord Infarction After Repair of Aortic Aneurysm or Dissection
    Ovid Technologies (Wolters Kluwer Health) ; 2017
    In:  Stroke Vol. 48, No. 8 ( 2017-08), p. 2073-2077
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 48, No. 8 ( 2017-08), p. 2073-2077
    Abstract: The rate of spinal cord infarction (SCI) after surgical or endovascular repair of an aortic aneurysm or dissection is unclear. Methods— Using administrative claims data, we identified adult patients discharged from nonfederal acute care hospitals in California, New York, and Florida who underwent surgical or endovascular repair of an aortic aneurysm or dissection between 2005 and 2013. Patients with SCI diagnosed before the aortic repair were excluded. Our primary outcome was an SCI during the index hospitalization for aortic repair. Descriptive statistics were used to estimate crude rates of SCI. Analyses were stratified by whether the aneurysm or dissection had ruptured and by type of repair (surgical versus endovascular). Results— We identified 91 212 patients who had repair of an aortic aneurysm or dissection. SCI occurred in 235 cases (0.26%; 95% confidence interval [CI], 0.22%–0.29%). In patients with ruptured aneurysm or dissection, the rate of SCI was 0.74% (95% CI, 0.60%–0.88%) compared with 0.16% (95% CI, 0.13%–0.19%) with unruptured aneurysm. In secondary analyses, rates of SCI were similar after endovascular repair (0.91%; 95% CI, 0.62%–1.19%) compared with surgical repair (0.68%; 95% CI, 0.53%–0.83%; P =0.147) of ruptured aortic aneurysm or dissection; however, rates of SCI were higher after surgical repair (0.20%; 95% CI, 0.15%–0.25%) versus endovascular repair (0.11%; 95% CI, 0.08%–0.14%; P 〈 0.001) of unruptured aneurysm. Conclusions— SCI occurs in ≈1 in 130 patients undergoing aortic dissection or ruptured aortic aneurysm repair and in 1 in 600 patients undergoing unruptured aortic aneurysm repair.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.117.017071
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2017
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  • 3
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    Abstract 47: Incidence of Cervical Artery Dissection Across Age Groups
    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: Dissection of a cervical artery has been well described as a cause of ischemic stroke in the young. The role of dissection as a cause of stroke among older adults is less clear, but there are no obvious reasons why older patients would have less of a predisposition to dissection than younger patients. Hypothesis: We hypothesized that the incidence of dissection-related ischemic stroke would remain constant across age. Methods: We used inpatient discharge data included in the 2012-2015 releases of the National Inpatient Survey (NIS). We used previously validated ICD-9-CM codes to identify adults who were hospitalized with ischemic stroke and a concomitant diagnosis of either carotid- or vertebral-artery dissection. We compared the prevalence of concomitant dissection among stroke hospitalizations across patient subgroups defined by age. Survey weights provided by the NIS were used to calculate nationally representative estimates. Population estimates from the U.S. census were used to calculate the incidence of hospitalization with stroke and concomitant dissection per million person-years. Results: From 2012-2015, there were 17,325 hospitalizations with ischemic stroke and a concomitant dissection in the US. The prevalence of cervical-artery dissection among stroke hospitalizations was highest among those under 40 years of age and gradually decreased across increasing 10-year age intervals (Figure 1A). On the other hand, the overall incidence of hospitalization for stroke and concomitant dissection increased with increasing age (Figure 1B). Conclusions: In a nationally representative sample, we found that cervical-artery dissection accounts for a greater proportion of ischemic strokes among younger patients, but the absolute incidence of dissection-related stroke increases with age.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.50.suppl_1.47
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 4
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    Abstract 117: Relationship Between Presence of Visceral Infarction and Functional Outcome Among Patients with Acute Ischemic Stroke
    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: Background: Evidence of visceral infarction is often found in patients with acute ischemic stroke, and appears to be more common among patients with embolic stroke subtypes. It remains uncertain whether there exists a relationship between visceral infarction and functional outcomes among patients with stroke. Methods: Among patients with acute ischemic stroke enrolled in the Cornell AcutE Stroke Academic Registry (CAESAR) from 2011 through 2016, we included those with a contrast-enhanced abdominal computed tomographic scan within 1 year of admission. Our outcome was ambulatory status at discharge from the acute stroke hospitalization, defined as walking without assistance, walking with assistance, and unable to walk. We used ordinal logistic regression to examine the association between visceral infarction and discharge ambulatory status after adjustment for demographics, stroke risk factors, stroke severity (NIH Stroke Scale score) and stroke subtype. Results: Among 2,116 ischemic stroke patients registered in CAESAR from 2011-2016, 228 had contrast-enhanced abdominopelvic computed tomographic imaging, of whom 40 (18%) had evidence of visceral infarction. Among the 188 patients without visceral infarction, 125 (66%) patients were discharged walking without assistance, 34 (18%) patients could walk with assistance, and 29 (15%) patients could not walk. In comparison, among the 40 patients with visceral infarction, 18 (45%) patients were discharged walking without assistance, 9 (23%) patients could walk with assistance, and 13 (33%) patients could not walk. After adjustment for demographics, stroke risk factors, stroke severity and stroke subtype, the presence of visceral infarction was associated with a worse ambulatory status (global OR for better ambulatory status, 0.3; 95% CI, 0.1-0.8). Conclusions: We found that the presence of visceral infarction, which is often incidentally detected on imaging among stroke patients, was associated with poor functional outcomes at the time of hospital discharge. These findings suggest that such incidental findings are not benign and are at the least a marker of poor outcomes.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.50.suppl_1.117
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 5
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    Risk of Pulmonary Embolism After Cerebral Venous Thrombosis
    Ovid Technologies (Wolters Kluwer Health) ; 2017
    In:  Stroke Vol. 48, No. 3 ( 2017-03), p. 563-567
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 48, No. 3 ( 2017-03), p. 563-567
    Abstract: Cerebral vein thrombosis (CVT) is a type of venous thromboembolism. Whether the risk of pulmonary embolism (PE) after CVT is similar to the risk after deep venous thrombosis (DVT) is unknown. Methods— We performed a retrospective cohort study using administrative data from all emergency department visits and hospitalizations in California, New York, and Florida from 2005 to 2013. We identified patients with CVT or DVT and the outcome of PE using previously validated International Classification of Diseases, Ninth Revision, Clinical Modification codes. Kaplan–Meier survival statistics and Cox proportional hazards models were used to compare the risk of PE after CVT versus PE after DVT. Results— We identified 4754 patients with CVT and 241 276 with DVT. During a mean follow-up of 3.4 (±2.4) years, 138 patients with CVT and 23 063 with DVT developed PE. CVT patients were younger, more often female, and had fewer risk factors for thromboembolism than patients with DVT. During the index hospitalization, the rate of PE was 1.4% (95% confidence interval [CI], 1.1%–1.8%) in patients with CVT and 6.6% (95% CI, 6.5%–6.7%) in patients with DVT. By 5 years, the cumulative rate of PE after CVT was 3.4% (95% CI, 2.9%–4.0%) compared with 10.9% (95% CI, 10.8%–11.0%; P 〈 0.001) after DVT. CVT was associated with a lower adjusted hazard of PE than DVT (hazard ratio, 0.26; 95% CI, 0.22–0.31). Conclusion— The risk of PE after CVT was significantly lower than the risk after DVT. Among patients with CVT, the greatest risk for PE was during the index hospitalization.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.116.016316
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2017
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  • 6
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    Restarting Anticoagulant Therapy After Intracranial Hemorrhage : A Systematic Review and Meta-Analysis
    Ovid Technologies (Wolters Kluwer Health) ; 2017
    In:  Stroke Vol. 48, No. 6 ( 2017-06), p. 1594-1600
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 48, No. 6 ( 2017-06), p. 1594-1600
    Abstract: The safety and efficacy of restarting anticoagulation therapy after intracranial hemorrhage (ICH) remain unclear. We performed a systematic review and meta-analysis to summarize the associations of anticoagulation resumption with the subsequent risk of ICH recurrence and thromboembolism. Methods— We searched published medical literature to identify cohort studies involving adults with anticoagulation-associated ICH. Our predictor variable was resumption of anticoagulation. Outcome measures were thromboembolic events (stroke and myocardial infarction) and recurrence of ICH. After assessing study heterogeneity and publication bias, we performed a meta-analysis using random-effects models to assess the strength of association between anticoagulation resumption and our outcomes. Results— Eight studies were eligible for inclusion in the meta-analysis, with 5306 ICH patients. Almost all studies evaluated anticoagulation with vitamin K antagonists. Reinitiation of anticoagulation was associated with a significantly lower risk of thromboembolic complications (pooled relative risk, 0.34; 95% confidence interval, 0.25–0.45; Q =5.12, P for heterogeneity=0.28). There was no evidence of increased risk of recurrent ICH after reinstatement of anticoagulation therapy, although there was significant heterogeneity among included studies (pooled relative risk, 1.01; 95% confidence interval, 0.58–1.77; Q =24.68, P for heterogeneity 〈 0.001). No significant publication bias was detected in our analyses. Conclusions— In observational studies, reinstitution of anticoagulation after ICH was associated with a lower risk of thromboembolic complications and a similar risk of ICH recurrence. Randomized clinical trials are needed to determine the true risk–benefit profile of anticoagulation resumption after ICH.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.116.016327
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2017
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  • 7
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    Population-Based Assessment of the Long-Term Risk of Seizures in Survivors of Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Stroke Vol. 49, No. 6 ( 2018-06), p. 1319-1324
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 49, No. 6 ( 2018-06), p. 1319-1324
    Abstract: We sought to determine the long-term risk of seizures after stroke according to age, sex, race, and stroke subtype. Methods— We performed a retrospective cohort study using administrative claims from 2 complementary patient data sets. First, we analyzed data from all emergency department visits and hospitalizations in California, Florida, and New York from 2005 to 2013. Second, we evaluated inpatient and outpatient claims from a nationally representative 5% random sample of Medicare beneficiaries. Our cohort consisted of all adults at the time of acute stroke hospitalization without a prior history of seizures. Our outcome was seizure occurring after hospital discharge for stroke. Poisson regression and demographic data were used to calculate age-, sex-, and race-standardized incidence rate ratios (IRR). Results— Among 777 276 patients in the multistate cohort, the annual incidence of seizures was 1.68% (95% confidence interval [CI], 1.67%–1.70%) after stroke versus 0.15% (95% CI, 0.15%–0.15%) among the general population (IRR, 7.3; 95% CI, 7.3–7.4). By 8 years, the cumulative rate of any emergency department visit or hospitalization for seizure was 9.27% (95% CI, 9.16%–9.38%) after stroke versus 1.21% (95% CI, 1.21%–1.22%) in the general population. Stroke was more strongly associated with a subsequent seizure among patients 〈 65 years of age (IRR, 12.0; 95% CI, 11.9–12.2) than in patients ≥65 years of age (IRR, 5.5; 95% CI, 5.4–5.5) and in the multistate analysis, the association between stroke and seizure was stronger among nonwhite patients (IRR, 11.0; 95% CI, 10.8–11.2) than among white patients (IRR, 7.3; 95% CI, 7.2–7.4). Risks were especially elevated after intracerebral hemorrhage (IRR, 13.3; 95% CI, 13.0–13.6) and subarachnoid hemorrhage (IRR, 13.2; 95% CI, 12.8–13.7). Our study of Medicare beneficiaries confirmed these findings. Conclusions— Almost 10% of patients with stroke will develop seizures within a decade. Hemorrhagic stroke, nonwhite race, and younger age seem to confer the greatest risk of developing seizures.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.117.020178
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
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  • 8
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    Machine Learning Prediction of Stroke Mechanism in Embolic Strokes of Undetermined Source
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Stroke Vol. 51, No. 9 ( 2020-09)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 51, No. 9 ( 2020-09)
    Abstract: One-fifth of ischemic strokes are embolic strokes of undetermined source (ESUS). Their theoretical causes can be classified as cardioembolic versus noncardioembolic. This distinction has important implications, but the categories’ proportions are unknown. Methods: Using data from the Cornell Acute Stroke Academic Registry, we trained a machine-learning algorithm to distinguish cardioembolic versus non-cardioembolic strokes, then applied the algorithm to ESUS cases to determine the predicted proportion with an occult cardioembolic source. A panel of neurologists adjudicated stroke etiologies using standard criteria. We trained a machine learning classifier using data on demographics, comorbidities, vitals, laboratory results, and echocardiograms. An ensemble predictive method including L1 regularization, gradient-boosted decision tree ensemble (XGBoost), random forests, and multivariate adaptive splines was used. Random search and cross-validation were used to tune hyperparameters. Model performance was assessed using cross-validation among cases of known etiology. We applied the final algorithm to an independent set of ESUS cases to determine the predicted mechanism (cardioembolic or not). To assess our classifier’s validity, we correlated the predicted probability of a cardioembolic source with the eventual post-ESUS diagnosis of atrial fibrillation. Results: Among 1083 strokes with known etiologies, our classifier distinguished cardioembolic versus noncardioembolic cases with excellent accuracy (area under the curve, 0.85). Applied to 580 ESUS cases, the classifier predicted that 44% (95% credibility interval, 39%–49%) resulted from cardiac embolism. Individual ESUS patients’ predicted likelihood of cardiac embolism was associated with eventual atrial fibrillation detection (OR per 10% increase, 1.27 [95% CI, 1.03–1.57]; c-statistic, 0.68 [95% CI, 0.58–0.78]). ESUS patients with high predicted probability of cardiac embolism were older and had more coronary and peripheral vascular disease, lower ejection fractions, larger left atria, lower blood pressures, and higher creatinine levels. Conclusions: A machine learning estimator that distinguished known cardioembolic versus noncardioembolic strokes indirectly estimated that 44% of ESUS cases were cardioembolic.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.120.029305
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
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  • 9
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    Prevalence of Cervical Artery Dissection Among Hospitalized Patients With Stroke by Age in a Nationally Representative Sample From the United States
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Neurology Vol. 96, No. 7 ( 2021-02-16), p. e1005-e1011
    Details
    In: Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 96, No. 7 ( 2021-02-16), p. e1005-e1011
    Abstract: To test the hypothesis that the prevalence of cervical artery dissection remains constant across age groups, we evaluated the relationship between age and cervical artery dissection in patients with stroke using a nationally representative sample from the United States. Methods We used inpatient claims data included in the 2012–2015 releases of the National Inpatient Sample (NIS). We used validated ICD-9-CM codes to identify adults hospitalized with ischemic stroke and a concomitant diagnosis of carotid or vertebral artery dissection. Survey weights provided by the NIS and population estimates from the US census were used to calculate nationally representative estimates. The χ 2 test for trend was used to compare the prevalence of concomitant dissection among stroke hospitalizations across patient subgroups defined by age. Poisson regression and the Wald test for trend were used to evaluate whether the prevalence of hospitalizations for stroke and concomitant dissection per million person-years varied by age groups. Results There were 17,320 (95% confidence interval [CI], 15,614–19,026) hospitalizations involving ischemic stroke and a concomitant dissection. The prevalence of dissection among stroke hospitalizations decreased across 10-year age groups from 7.2% (95% CI, 6.2%–8.1%) among persons younger than 30 years to 0.2% (95% CI, 0.1%–0.2%) among persons older than 80 years ( p value for trend 〈 0.001). However, the prevalence of hospitalizations for stroke and concomitant dissection increased from 5.4 (95% CI, 4.6–6.2) hospitalizations per million person-years among adults younger than 30 to 24.4 (95% CI, 21.0–27.9) hospitalizations per million person-years among adults older than age 80 ( p value for trend 〈 0.01). Conclusion In a nationally representative sample, the prevalence of hospitalizations for dissection-related stroke increased with age.
    Type of Medium: Online Resource
    ISSN: 0028-3878 , 1526-632X
    URL: Article
    DOI: 10.1212/WNL.0000000000011420
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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  • 10
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    Abstract TMP80: Temporal Trends in Ischemic Stroke Mortality Stratified by Presence of Cancer
    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: Background: About 5% of acute ischemic stroke (AIS) patients have active cancer. Previous work has shown that cancer patients are more likely to die after AIS than non-cancer patients. However, few data exist on how these disparities are changing over time. Methods: We identified all patients hospitalized with AIS in the National Inpatient Sample from 1996-2013 using validated ICD-9 diagnosis codes. Our primary predictor was systemic cancer, which was a composite of solid and hematologic tumors with or without metastases. Primary brain tumors were excluded. Our primary outcome was in-hospital death. Survey weights were used to estimate nationally-representative annual rates of in-hospital death among AIS patients with and without cancer. Multivariable logistic regression models adjusting for age, gender, and race were constructed to evaluate the relationship between time, cancer history, and mortality. Results: We identified 9.6 million patients with AIS, of whom 491,704 (5.1%) had cancer. The in-hospital death rate among stroke patients with cancer decreased from 21.7% (95% confidence interval [CI], 20.6-22.9%) in 1996 to 13.9% (95% CI, 13.0-14.7%) in 2013, while the death rate among stroke patients without cancer decreased from 9.9% (95% CI, 9.6-10.1%) in 1996 to 6.4% (95% CI, 6.2-6.6%) in 2013 (Figure). After adjustment for demographics, a cancer diagnosis was associated with more than a doubling in odds of death after AIS (odds ratio [OR] 2.34; 95% CI, 2.29-2.38). However, during the 18-year study period, the demographic-adjusted odds of in-hospital death after AIS decreased similarly over time in patients with cancer (OR per year 0.97; 95% CI, 0.96-0.97) as compared to those without (OR per year 0.97; 95% CI, 0.97-0.98). Conclusions: Despite improved mortality rates over time, cancer patients with AIS continue to face more than a two-fold increased risk of in-hospital death as compared to non-cancer AIS patients.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.49.suppl_1.TMP80
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
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