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Temporal trends of sex differences in acute reperfusion therapy and early outcomes of acute ischemic stroke in South Korea: 10-year analysis of the nationwide stroke registry. 韩国急性再灌注治疗和急性缺血性脑卒中早期预后的性别差异时间趋势:全国脑卒中登记处的十年分析。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-07-24 DOI: 10.1177/17474930241261877
Darda Chung, Ji Sung Lee, Mi-Sun Oh, Jong-Moo Park, Jong-Won Chung, Oh Young Bang, Gyeong-Moon Kim, Woo-Keun Seo

Background: Sex differences in stroke outcomes are notable, with women experiencing higher incidence rates, greater disability-adjusted life years, and poorer recovery compared to men, even after adjusting for age and comorbidities. Despite the disproportionate burden in women, studies have reported that women are less likely to receive appropriate stroke treatment than men.

Aim: This study investigated temporal trends of sex differences in acute reperfusion therapy and early outcomes in patients with acute ischemic stroke over 10 years in South Korea.

Methods: A retrospective analysis of Korean Stroke Registry included patients with acute ischemic stroke from 2012 to 2021. The study outcomes were the temporal trends of acute reperfusion therapy and early outcomes over 10 years in men and women, respectively. In addition, this study analyzed the temporal trends of sex differences in these parameters during the same period. Early outcomes include the proportions of favorable functional outcomes at discharge, discharge patterns, and in-hospital mortality.

Results: A total of 93,692 patients (68.4 years, 40.1% women) with acute ischemic stroke were finally enrolled. Women had a higher age at stroke onset, a higher prevalence of atrial fibrillation, and more severe strokes than men. Women had lower proportion of favorable functional outcomes at discharge and higher proportion of in-hospital mortality compared to men each year. The proportion of patients who received intravenous thrombolysis was lower or similar in women compared to men in most years, and the proportion of patients who received endovascular thrombectomy did not significantly differ between sexes annually. Sex differences in acute reperfusion therapy remained unchanged over 10 years.

Conclusion: Women have received acute reperfusion therapy at similar or lower rates than men and experienced poorer outcomes, despite having more stroke risk factors and often more severe strokes.

背景:与男性相比,女性的发病率更高、残疾调整生命年数更长、恢复更差,即使在调整年龄和合并症后也是如此。目的:本研究调查了韩国急性缺血性卒中患者急性再灌注治疗和早期预后 10 年来的性别差异时间趋势:方法:对韩国卒中登记处进行回顾性分析,纳入 2012 年至 2021 年的急性缺血性卒中患者。研究结果显示,男性和女性急性再灌注治疗和早期预后的时间趋势分别为 10 年。此外,本研究还分析了同期这些参数的性别差异时间趋势。早期预后包括出院时良好功能预后的比例、出院模式和院内死亡率:共有 93,692 名急性缺血性脑卒中患者(68.4 岁,40.1% 为女性)最终入选。与男性相比,女性中风发病年龄更高,心房颤动发生率更高,中风程度更严重。与男性相比,女性出院时获得良好功能预后的比例较低,每年的院内死亡率较高。在大多数年份中,女性与男性相比接受静脉溶栓治疗的比例较低或相似,而每年接受血管内血栓切除术的患者比例在性别上没有显著差异。急性再灌注治疗的性别差异在10年中保持不变:结论:女性接受急性再灌注治疗的比例与男性相似或更低,尽管她们有更多的中风风险因素,中风程度往往也更严重,但她们的治疗效果却更差。
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引用次数: 0
Relationship between carotid web morphology on CT angiography and stroke: A pooled multicenter analysis. CT 血管造影上颈动脉网形态与中风之间的关系:多中心汇总分析
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-07-31 DOI: 10.1177/17474930241264141
Fouzi Bala, Ibrahim Alhabli, Nishita Singh, Faysal Benali, Shelagh Coutts, Mayank Goyal, Mohammed Almekhlafi, Michael D Hill, Bijoy K Menon

Background: The Carotid web (CaW) is a cause of stroke, particularly in younger individuals. However, the frequency and the radiological features of the web's morphology associated with stroke risk are uncertain. We determined the CaW radiological features on computed tomography (CT) angiography associated with ipsilateral stroke.

Materials and methods: Data from six studies of patients with acute ischemic stroke were pooled. Identification and measurement of CaWs were performed by experienced readers using baseline neck CT angiography. We assessed six 2D CaW radiological features on sagittal oblique images, namely, main axis length, thickness, height, base width, distance to wall, and angle between the web main axis and carotid wall, and CaW volume on 3D images. CaWs were divided into symptomatic if acute ischemic stroke was in the ipsilateral internal carotid artery territory and its etiology was undetermined and asymptomatic if one condition was unmet. Univariable and multivariable analyses were conducted to assess the association between each radiological CaW feature and symptomatic CaW.

Results: Of the 3442 patients in the pooled data with assessable CTAs, 60 (1.7%) had CaW. In patients with CaW, median age was 59 (interquartile range [IQR]: 50-68) years, 60% were women, and 3 patients had bilateral CaWs. There were 39 (62%) symptomatic and 24 (38%) asymptomatic CaWs. Patients with symptomatic CaW were younger (55 (IQR: 49-61) years versus 69 (IQR: 52-75) years), had lower rates of hypertension (9 (25.0%) versus 12 (57.1%)) and more intracranial large vessel occlusions compared to patients with asymptomatic CaWs. After adjusting for age, hypertension, and occlusion location, CaW length (adjusted odds ratio (aOR) 1.84 (95% confidence interval [CI]: 1.03-3.28)), thickness (aOR: 2.31 (95% CI 1.08-4.97)), volume (aOR: 1.07 per 1 mm3 increment (95% CI: 1.01-1.12)), and angle relative to the carotid wall (aOR: 0.95 (95% CI: 0.91-0.99)) were associated with symptomatic CaW.

Conclusion: Radiological assessment of CaW morphology may determine its potential causal role in ischemic stroke etiology. Symptomatic CaWs tend to be longer, larger, and oriented at more acute angles relative to the carotid wall as compared to asymptomatic CaWs.

背景:颈动脉网(CaW)是中风的诱因之一,尤其是在年轻人中。然而,它的发生频率以及与中风风险相关的颈动脉网形态学特征尚不确定。我们确定了 CT 血管造影上与同侧中风相关的颈动脉蛛网膜放射学特征:汇总了六项急性缺血性卒中患者的研究数据。由经验丰富的读者对基线颈部 CT 血管造影上的 CaW 进行识别和测量。我们在矢状斜面图像上评估了六个二维CaW放射学特征,即主轴长度、厚度、高度、基底宽度、与壁的距离、网状主轴与颈动脉壁之间的角度,以及三维图像上的CaW体积。如果急性缺血性卒中发生在同侧颈内动脉区域,且病因未确定,则将CaW分为有症状和无症状两种。研究人员进行了单变量和多变量分析,以评估各放射学CaW特征与无症状CaW之间的关联:在汇集数据的 3442 名可评估 CTA 的患者中,有 60 人(1.7%)有 CaW。CaW患者的中位年龄为59岁(IQR为50-68岁),60%为女性,3名患者为双侧CaW。有症状的 CaW 患者有 39 人(62%),无症状的有 24 人(38%)。与无症状颅脑损伤患者相比,有症状的颅脑损伤患者更年轻(55 [IQR 49-61] 岁对 69 [IQR 52-75] 岁),高血压发病率更低(9 [25.0%] 对 12 [57.1%]),颅内大血管闭塞更多。在对年龄、高血压和闭塞位置进行调整后,CaW 长度(调整后的几率比 [aOR] 1.84 [95%CI 1.03-3.28])、厚度(aOR 2.31 [95%CI 1.08-4.97])、体积(aOR 1.07 per 1 mm3 increment [95%CI 1.01-1.12])和相对于颈动脉壁的角度(aOR 0.95 [95%CI 0.91-0.99])与无症状 CaW 相关:结论:CaW 形态的放射学评估可确定其在缺血性卒中病因中的潜在作用。与无症状的CaW相比,有症状的CaW往往更长、更大,且相对于颈动脉壁的角度更尖锐。
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引用次数: 0
Predicting post-stroke cognitive impairment using electronic health record data. 利用电子健康记录数据预测中风后的认知障碍。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-04-18 DOI: 10.1177/17474930241246156
Jeffrey M Ashburner, Yuchiao Chang, Bianca Porneala, Sanjula D Singh, Nirupama Yechoor, Jonathan M Rosand, Daniel E Singer, Christopher D Anderson, Steven J Atlas

Background: Secondary prevention interventions to reduce post-stroke cognitive impairment (PSCI) can be aided by the early identification of high-risk individuals who would benefit from risk factor modification.

Aims: To develop and evaluate a predictive model to identify patients at increased risk of PSCI over 5 years using data easily accessible from electronic health records.

Methods: Cohort study that included primary care patients from two academic medical centers. Patients were aged 45 years or older, without prior stroke or prevalent cognitive impairment, with primary care visits and an incident ischemic stroke between 2003 and 2016 (development/internal validation cohort) or 2010 and 2022 (external validation cohort). Predictors of PSCI were ascertained from the electronic health record. The outcome was incident dementia/cognitive impairment within 5 years and beginning 3 months following stroke, ascertained using International Classification of Diseases, Ninth/Tenth Revision (ICD-9/10) codes. For model variable selection, we considered potential predictors of PSCI and constructed 400 bootstrap samples with two-thirds of the model derivation sample. We ran 10-fold cross-validated Cox proportional hazards models using a least absolute shrinkage and selection operator (LASSO) penalty. Variables selected in >25% of samples were included.

Results: The analysis included 332 incident diagnoses of PSCI in the development cohort (n = 3741), and 161 and 128 incident diagnoses in the internal (n = 1925) and external (n = 2237) validation cohorts, respectively. The C-statistic for predicting PSCI was 0.731 (95% confidence interval (CI): 0.694-0.768) in the internal validation cohort, and 0.724 (95% CI: 0.681-0.766) in the external validation cohort. A risk score based on the beta coefficients of predictors from the development cohort stratified patients into low (0-7 points), intermediate (8-11 points), and high (12-23 points) risk groups. The hazard ratios (HRs) for incident PSCI were significantly different by risk categories in internal (high, HR: 6.2, 95% CI: 4.1-9.3; Intermediate, HR: 2.7, 95% CI: 1.8-4.1) and external (high, HR: 6.1, 95% CI: 3.9-9.6; Intermediate, HR: 2.8, 95% CI: 1.9-4.3) validation cohorts.

Conclusion: Five-year risk of PSCI can be accurately predicted using routinely collected data. Model output can be used to risk stratify and identify individuals at increased risk for PSCI for preventive efforts.

Data access statement: Mass General Brigham data contain protected health information and cannot be shared publicly. The data processing scripts used to perform analyses will be made available to interested researchers upon reasonable request to the corresponding author.

背景:目的:利用易于从电子健康记录中获取的数据,开发并评估一个预测模型,以识别5年内卒中后认知障碍(PSCI)风险增加的患者:方法:队列研究,包括两个学术医疗中心的初级保健患者。患者年龄在 45 岁或以上,既往无中风或普遍存在认知障碍,在 2003-2016 年(开发/内部验证队列)或 2010-2022 年(外部验证队列)期间接受过初级保健就诊并发生过缺血性中风。从电子健康记录中确定了 PSCI 的预测因素。结果是中风后 3 个月开始的 5 年内发生的痴呆/认知障碍,使用 ICD-9/10 编码确定。在选择模型变量时,我们考虑了 PSCI 的潜在预测因子,并用模型推导样本的三分之二构建了 400 个引导样本。我们使用最小绝对收缩和选择算子(LASSO)惩罚法运行了 10 倍交叉验证的 Cox 比例危险模型。结果:分析包括开发队列(n=3,741)中的 332 例 PSCI 诊断病例,以及内部(n=1,925)和外部(n=2,237)验证队列中的 161 例和 128 例诊断病例。内部验证队列中预测 PSCI 的 c 统计量为 0.731(95% CI:0.694-0.768),外部验证队列中预测 PSCI 的 c 统计量为 0.724(95% CI:0.681-0.766)。根据开发队列中预测因子的贝塔系数进行风险评分,将患者分为低(0-7 分)、中(8-11 分)和高(12-35 分)风险组。在内部(高危,HR:6.2,95% CI:4.1-9.3;中危,HR:2.7,95% CI:1.8-4.1)和外部(高危,HR:6.1,95% CI:3.9-9.6;中危,HR:2.8,95% CI:1.9-4.3)验证队列中,不同风险类别的患者发生 PSCI 的危险比存在显著差异:结论:利用常规收集的数据可以准确预测五年的 PSCI 风险。模型输出结果可用于风险分层,并识别出 PSCI 风险增加的个体,以便采取预防措施。数据访问声明:Mass General Brigham 数据包含受保护的健康信息,不能公开共享。用于执行分析的数据处理脚本将在向通讯作者提出合理要求后提供给感兴趣的研究人员。
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引用次数: 0
Post-stroke cognitive impairment remains highly prevalent and disabling despite state-of-the-art stroke treatment. 尽管采用了最先进的中风治疗方法,但中风后认知障碍的发生率和致残率仍然很高。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-03-21 DOI: 10.1177/17474930241238637
Laura Gallucci, Christoph Sperber, Adrian G Guggisberg, Christoph P Kaller, Mirjam R Heldner, Andreas U Monsch, Arsany Hakim, Norbert Silimon, Urs Fischer, Marcel Arnold, Roza M Umarova

Background: State-of-the-art stroke treatment significantly reduces lesion size and stroke severity, but it remains unclear whether these therapeutic advances have diminished the burden of post-stroke cognitive impairment (PSCI).

Aims: In a cohort of patients receiving modern state-of-the-art stroke care including endovascular therapy, we assessed the frequency of PSCI and the pattern of domain-specific cognitive deficits, identified risk factors for PSCI, and determined the impact of acute PSCI on stroke outcome.

Methods: In this prospective monocentric cohort study, we examined patients with first-ever anterior circulation ischemic stroke without pre-stroke cognitive decline, using a comprehensive neuropsychological assessment ⩽10 days after symptom onset. Normative data were stratified by demographic variables. We defined PSCI as at least moderate (<1.5 standard deviation) deficits in ⩾2 cognitive domains. Multivariable regression analysis was applied to define risk factors for PSCI.

Results: We analyzed 329 non-aphasic patients admitted from December 2020 to July 2023 (67.2 ± 14.4 years old, 41.3% female, 13.1 ± 2.7 years of education). Although most patients had mild stroke (median National Institutes of Health Stroke Scale (NIHSS) 24 h = 1.00 (0.00; 3.00); 87.5% with NIHSS ⩽ 5), 69.3% of them presented with PSCI 2.7 ± 2.0 days post-stroke. The most severely and often affected cognitive domains were verbal learning, episodic memory, executive functions, selective attention, and constructive abilities (39.1%-51.2% of patients), whereas spatial neglect was less frequent (18.5%). The risk of PSCI was reduced with more years of education (odds ratio (OR) = 0.47, 95% confidence interval (CI) = 0.23-0.99) and right hemisphere lesions (OR = 0.47, 95% CI = 0.26-0.84), and increased with stroke severity (NIHSS 24 h, OR = 4.19, 95% CI = 2.72-6.45), presence of hyperlipidemia (OR = 1.93, 95% CI = 1.01-3.68), but was not influenced by age. After adjusting for stroke severity and depressive symptoms, acute PSCI was associated with poor functional outcome (modified Rankin Scale > 2, F = 13.695, p < 0.001) and worse global cognition (Montreal Cognitive Assessment (MoCA) score, F = 20.069, p < 0.001) at 3 months post-stroke.

Conclusion: Despite modern stroke therapy and many strokes having mild severity, PSCI in the acute stroke phase remains frequent and associated with worse outcome. The most prevalent were learning and memory deficits. Cognitive reserve operationalized as years of education independently protects post-stroke cognition.

背景:目的:在接受包括血管内治疗在内的现代最先进卒中治疗的患者队列中,我们评估了卒中后认知障碍的频率和特定领域认知障碍的模式,确定了卒中后认知障碍的风险因素,并确定了急性卒中后认知障碍对卒中结局的影响:在这项前瞻性单中心队列研究中,我们对症状发生后 10 天内首次发生前循环缺血性卒中且卒中前无认知功能下降的患者进行了全面的神经心理学评估。根据人口统计学变量对标准数据进行了分层。我们将 PSCI 定义为至少在 ≥ 2 个认知领域存在中度(< 1.5 SD)缺陷。多变量回归分析用于确定 PSCI 的风险因素:我们分析了 2020 年 12 月至 2023 年 7 月期间收治的 329 名非重症患者(67.2±14.4 岁,41.3% 为女性,13.1±2.7 年教育程度)。虽然大多数患者为轻度卒中(NIHSS 24h 中位数=1.00 [0.00; 3.00];87.5%的患者 NIHSS ≥ 5),但其中 69.3%的患者在卒中后 2.7±2.0 天出现 PSCI。受影响最严重和最常见的认知领域是言语学习、外显记忆、执行功能、选择性注意和建构能力(39.1%-51.2%的患者),而空间忽略较少见(18.5%)。受教育年限越长(几率比 [OR] 0.47,95% CI:0.23-0.99)、右半球病变(OR 0.47,95% CI:0.26-0.84),PSCI 的风险越低;中风严重程度(NIHSS 24h,OR 4.19,95% CI:2.72-6.45)、高脂血症(OR 1.93,95% CI:1.01-3.68)越高,PSCI 的风险越高,但不受年龄影响。在对卒中严重程度和抑郁症状进行调整后,急性 PSCI 与不良功能预后相关(改良 Rankin 量表 > 2,F=13.695,pF=20.069,pConclusions):尽管采用了现代中风治疗方法,且许多中风的严重程度较轻,但急性中风阶段的 PSCI 仍很常见,且与较差的预后有关。最常见的是学习和记忆障碍。以受教育年限为标准的认知储备可独立保护卒中后的认知能力。
{"title":"Post-stroke cognitive impairment remains highly prevalent and disabling despite state-of-the-art stroke treatment.","authors":"Laura Gallucci, Christoph Sperber, Adrian G Guggisberg, Christoph P Kaller, Mirjam R Heldner, Andreas U Monsch, Arsany Hakim, Norbert Silimon, Urs Fischer, Marcel Arnold, Roza M Umarova","doi":"10.1177/17474930241238637","DOIUrl":"10.1177/17474930241238637","url":null,"abstract":"<p><strong>Background: </strong>State-of-the-art stroke treatment significantly reduces lesion size and stroke severity, but it remains unclear whether these therapeutic advances have diminished the burden of post-stroke cognitive impairment (PSCI).</p><p><strong>Aims: </strong>In a cohort of patients receiving modern state-of-the-art stroke care including endovascular therapy, we assessed the frequency of PSCI and the pattern of domain-specific cognitive deficits, identified risk factors for PSCI, and determined the impact of acute PSCI on stroke outcome.</p><p><strong>Methods: </strong>In this prospective monocentric cohort study, we examined patients with first-ever anterior circulation ischemic stroke without pre-stroke cognitive decline, using a comprehensive neuropsychological assessment ⩽10 days after symptom onset. Normative data were stratified by demographic variables. We defined PSCI as at least moderate (<1.5 standard deviation) deficits in ⩾2 cognitive domains. Multivariable regression analysis was applied to define risk factors for PSCI.</p><p><strong>Results: </strong>We analyzed 329 non-aphasic patients admitted from December 2020 to July 2023 (67.2 ± 14.4 years old, 41.3% female, 13.1 ± 2.7 years of education). Although most patients had mild stroke (median National Institutes of Health Stroke Scale (NIHSS) 24 h = 1.00 (0.00; 3.00); 87.5% with NIHSS ⩽ 5), 69.3% of them presented with PSCI 2.7 ± 2.0 days post-stroke. The most severely and often affected cognitive domains were verbal learning, episodic memory, executive functions, selective attention, and constructive abilities (39.1%-51.2% of patients), whereas spatial neglect was less frequent (18.5%). The risk of PSCI was reduced with more years of education (odds ratio (OR) = 0.47, 95% confidence interval (CI) = 0.23-0.99) and right hemisphere lesions (OR = 0.47, 95% CI = 0.26-0.84), and increased with stroke severity (NIHSS 24 h, OR = 4.19, 95% CI = 2.72-6.45), presence of hyperlipidemia (OR = 1.93, 95% CI = 1.01-3.68), but was not influenced by age. After adjusting for stroke severity and depressive symptoms, acute PSCI was associated with poor functional outcome (modified Rankin Scale > 2, F = 13.695, p < 0.001) and worse global cognition (Montreal Cognitive Assessment (MoCA) score, F = 20.069, p < 0.001) at 3 months post-stroke.</p><p><strong>Conclusion: </strong>Despite modern stroke therapy and many strokes having mild severity, PSCI in the acute stroke phase remains frequent and associated with worse outcome. The most prevalent were learning and memory deficits. Cognitive reserve operationalized as years of education independently protects post-stroke cognition.</p>","PeriodicalId":14442,"journal":{"name":"International Journal of Stroke","volume":null,"pages":null},"PeriodicalIF":6.3,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139996210","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Prevalence of right-to-left shunt in stroke patients with cancer. 癌症中风患者右左分流的发病率。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-06-13 DOI: 10.1177/17474930241260589
Fabienne Steinauer, Philipp Bücke, Eric Buffle, Mattia Branca, Jayan Göcmen, Babak B Navi, Ava L Liberman, Anna Boronylo, Leander Clenin, Martina Goeldlin, Julian Lippert, Bastian Volbers, Thomas R Meinel, David Seiffge, Adnan Mujanovic, Johannes Kaesmacher, Urs Fischer, Marcel Arnold, Thomas Pabst, Martin D Berger, Simon Jung, Morin Beyeler

Background and objectives: Cancer is associated with an increased risk of acute ischemic stroke (AIS) and venous thromboembolism. The role of a cardiac right-to-left shunt (RLS) as a surrogate parameter for paradoxical embolism in cancer-related strokes is uncertain. We sought to investigate the relationship between the presence of an RLS and cancer in AIS patients.

Methods: We included consecutive AIS patients hospitalized at our tertiary stroke center between January 2015 and December 2020 with available RLS status as detected on transesophageal echocardiography (TEE). Active cancers were retrospectively identified and the association with RLS was assessed with multivariable logistic regression and inverse probability of treatment weighting to minimize the ascertainment bias of having a TEE obtained.

Results: Of the 2236 AIS patients included, 103 (4.6%) had active cancer, of whom 24 (23%) were diagnosed with RLS. An RLS was present in 774 out of the 2133 AIS patients without active cancer (36%). After adjustment and weighting, the absence of RLS was associated with active cancer (adjusted odds ratio (aOR) 2.29; 95% confidence interval (CI), 1.14-4.58). When analysis was restricted to patients younger than 60 years of age or those with a high-risk RLS (Risk of Paradoxical Embolism Score ⩾ 6), there was no association between RLS and cancer (aOR, 3.07; 95% CI, 0.79-11.88 and aOR, 0.56; 95% CI, 0.10-3.10, respectively).

Conclusion: RLS was diagnosed less frequently in AIS patients with cancer than in cancer-free patients, suggesting that arterial sources may play a larger role in cancer-related strokes than paradoxical venous embolization. Future studies are needed to validate these findings and evaluate potential therapeutic implications, such as the general indication, or lack thereof, for patent foramen ovale (PFO) closure in this patient population.

背景和目的:癌症与急性缺血性脑卒中(AIS)和静脉血栓栓塞风险增加有关。心脏右左分流(RLS)作为矛盾性栓塞的替代指标在癌症相关中风中的作用尚不确定。我们试图研究 AIS 患者出现 RLS 与癌症之间的关系:我们纳入了 2015 年 1 月至 2020 年 12 月期间在我们的三级卒中中心住院的连续 AIS 患者,这些患者经食道超声心动图(TEE)检测出 RLS 状态。对活动性癌症进行了回顾性鉴别,并通过多变量逻辑回归和逆治疗概率加权评估了与RLS的关系,以尽量减少经食道超声心动图检查的确定偏倚:在纳入的 2236 名 AIS 患者中,103 人(4.6%)患有活动性癌症,其中 24 人(23%)被诊断为 RLS。在2133名无活动性癌症的AIS患者中,有774人(36%)患有RLS。经过调整和加权后,无 RLS 与癌症活动有关(调整后的几率比 [aOR],2.29;95% 置信区间 [CI],1.14-4.58)。当分析对象仅限于年龄小于60岁或RLS风险较高的患者(并发栓塞风险评分≥6分)时,RLS与癌症之间没有关联(aOR,3.07;95% CI,0.79-11.88;aOR,0.56;95% CI,0.10-3.10):结论:与未患癌症的患者相比,AIS 癌症患者被诊断出 RLS 的频率较低,这表明动脉源在癌症相关中风中的作用可能大于矛盾性静脉栓塞。未来的研究需要验证这些发现,并评估潜在的治疗意义,如在这一患者群体中关闭 PFO 的一般适应症或缺乏适应症。
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引用次数: 0
Reperfusion therapies for ischemic stroke in dementia and cognitive impairment: A systematic review and meta-analysis. 再灌注治疗缺血性脑卒中痴呆和认知功能障碍:系统回顾和荟萃分析。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2023-12-27 DOI: 10.1177/17474930231220186
Fouzi Bala, William Betzner, Benjamin Beland, Jennifer S McDonald, Aravind Ganesh

Background: Endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) have an unclear benefit in those with pre-stroke dementia or cognitive impairment, as these patients were often excluded from landmark stroke trials. We performed a systematic review and meta-analysis to assess the outcomes of IVT and EVT in these populations.

Aims: Our systematic review, conforming to the Meta-Analysis of Observational Studies in Epidemiology guidelines, investigated studies on acute ischemic stroke patients with pre-stroke dementia or cognitive impairment treated with IVT or EVT. Primary outcome was favorable 90-day outcome (mRS 0-2). Secondary outcomes included 90-day mortality, symptomatic intracranial hemorrhage (SICH), and radiographic intracranial hemorrhage (ICH).

Summary of review: Nine articles were identified, with five observational studies of IVT use in patients with (n = 1078) and without dementia (n = 2805) being selected for the meta-analysis. There were no significant differences in favorable outcome (adjusted OR: 0.61, 95% CI 0.24-1.59), mortality (unadjusted OR: 1.19, 95% CI 0.86-1.64), ICH (unadjusted OR: 1.32, 95% CI 0.79-2.19), and symptomatic ICH (unadjusted OR: 0.94, 95% CI 0.70-1.25) for patients undergoing IVT with pre-stroke dementia versus those without. One EVT study (n = 615 with dementia vs n = 9600 without) found no significant differences in outcomes apart from an increased odds of ICH for those with pre-existing dementia (adjusted OR: 1.57, 95% CI 1.03-2.40). A pooled analysis of three IVT studies showed no significant association of cognitive impairment (n = 93 vs n = 211 without) with all assessed outcomes, whereas a study of EVT found that pre-stroke cognitive impairment was associated with poor 90-day outcomes (mRS 3-6).

Conclusion: These results suggest no substantial safety issues in the use of IVT or EVT for patients with pre-existing dementia or cognitive impairment compared to those without. However, the efficacy of these therapies in this demographic remains uncertain. Further rigorous studies that include a more nuanced outcome measurement approach are warranted.

Registration: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021240499.

背景:血管内取栓(EVT)和静脉溶栓(IVT)对脑卒中前痴呆或认知障碍患者的益处尚不清楚,因为这些患者通常被排除在具有里程碑意义的脑卒中试验之外。我们进行了系统回顾和荟萃分析,以评估这些人群中IVT和EVT的结果。方法:根据流行病学指南中观察性研究的荟萃分析,我们确定了急性缺血性卒中合并卒中前痴呆或认知障碍患者接受IVT或EVT治疗的研究。主要转归为90天的有利转归(mRS 0-2)。次要结局包括90天死亡率、症状性颅内出血(SICH)和影像学颅内出血(ICH)。结果:纳入了9篇文章,其中5项观察性研究选择了IVT在有(n=1078)和无痴呆(n=2805)患者中的应用进行meta分析。接受IVT合并卒中前痴呆的患者与未接受IVT的患者在有利结局(校正OR:0.61, 95%CI 0.24-1.59)、死亡率(未校正OR: 1.19, 95%CI 0.86-1.64)、脑出血(未校正OR:1.32, 95%CI 0.79- 2.19)和症状性脑出血(未校正OR:0.94, 95%CI 0.70-1.25)方面无显著差异。一项EVT研究(n=615例痴呆患者vs n= 9600例无痴呆患者)发现,除了已存在痴呆患者脑出血的几率增加外,结果无显著差异(调整OR:1.57, 95%CI 1.03-2.40)。三项IVT研究的汇总分析显示,认知障碍与所有评估结果均无显著相关性(n=93 vs n=211),而EVT研究发现卒中前认知障碍与较差的90天预后(mRS 3-6)相关。结论:这些结果一般表明,与没有痴呆或认知障碍的患者相比,IVT或EVT用于已有痴呆或认知障碍的患者没有实质性的安全性问题。然而,这些疗法在这一人群中的疗效仍不确定。进一步严格的研究包括更细致的结果测量方法是有必要的。注册:网址:https://www.crd.york.ac.uk/PROSPERO/;唯一标识符:CRD42021240499。缩写:EVT:血管内血栓切除术,ICH:脑出血,IVT:静脉溶栓,MCI:轻度认知障碍,mRS:改良Rankin评分,MOOSE:流行病学观察性研究荟萃分析,PRISMA:系统评价和荟萃分析的首选报告项目,QUIPS:预后质量研究,SICH:症状性脑出血。
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引用次数: 0
Sensitivity of the Boston criteria version 2.0 in Dutch-type hereditary cerebral amyloid angiopathy. 波士顿标准 2.0 版对荷兰型遗传性脑淀粉样血管病的敏感性
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-03-21 DOI: 10.1177/17474930241239801
Rgj van der Zwet, E A Koemans, S Voigt, R van Dort, I Rasing, K Kaushik, T W van Harten, M R Schipper, G M Terwindt, Mjp van Osch, Maa van Walderveen, E S van Etten, Mjh Wermer

Background and aim: The revised Boston criteria v2.0 for cerebral amyloid angiopathy (CAA) add two radiological markers to the existing criteria: severe visible perivascular spaces in the centrum semiovale and white matter hyperintensities (WMHs) in a multispot pattern. This study aims to determine the sensitivity of the updated criteria in mutation carriers with Dutch-type hereditary CAA (D-CAA) in an early and later disease stage.

Methods: In this cross-sectional study, we included presymptomatic and symptomatic D-CAA mutation carriers from our prospective natural history study (AURORA) at the Leiden University Medical Center between 2018 and 2021. 3-Tesla scans were assessed for CAA-related magnetic resonance imaging (MRI) markers. We compared the sensitivity of the Boston criteria v2.0 to the previously used modified Boston criteria v1.5.

Results: We included 64 D-CAA mutation carriers (mean age 49 years, 55% women, 55% presymptomatic). At least one white matter (WM) feature was seen in 55/64 mutation carriers (86%: 74% presymptomatic, 100% symptomatic). Fifteen (23%) mutation carriers, all presymptomatic, showed only WM features and no hemorrhagic markers. The sensitivity for probable CAA was similar between the new and the previous criteria: 11/35 (31%) in presymptomatic mutation carriers and 29/29 (100%) in symptomatic mutation carriers. The sensitivity for possible CAA in presymptomatic mutation carriers increased from 0/35 (0%) to 15/35 (43%) with the new criteria.

Conclusion: The Boston criteria v2.0 increase the sensitivity for detecting possible CAA in presymptomatic D-CAA mutation carriers and, therefore, improve the detection of the early phase of CAA.

背景和目的:修订后的波士顿脑淀粉样血管病(CAA)标准v2.0在现有标准的基础上增加了两个放射学标志物:半卵圆中心的严重可见血管周围间隙和多点模式的白质高密度(WMH)。本研究旨在确定最新标准在荷兰型遗传性 CAA(D-CAA)突变携带者疾病早期和晚期阶段的敏感性:在这项横断面研究中,我们纳入了2018年至2021年间莱顿大学医学中心前瞻性自然史研究(AURORA)中的无症状和有症状的D-CAA突变携带者。3-Tesla 扫描评估了 CAA 相关的 MRI 标记。我们比较了波士顿标准v2.0与之前使用的修改后波士顿标准v1.5的敏感性:我们纳入了 64 名 D-CAA 基因突变携带者(平均年龄 49 岁,55% 为女性,55% 无症状)。55/64 例突变携带者中至少有一种白质(WM)特征(86%:74%无症状,100%有症状。15名突变携带者(23%)均无症状,仅表现出白质特征,无出血标记物。新标准和旧标准对疑似 CAA 的敏感性相似:在无症状突变携带者中,有11/35(31%)人可能患有CAA;在有症状突变携带者中,有29/29(100%)人可能患有CAA。新标准对无症状突变携带者中可能存在 CAA 的敏感性从 0/35 (0%) 增加到 15/35 (43%):波士顿标准v2.0提高了对无症状D-CAA突变携带者可能患有CAA的检测灵敏度,从而改善了对CAA早期阶段的检测。
{"title":"Sensitivity of the Boston criteria version 2.0 in Dutch-type hereditary cerebral amyloid angiopathy.","authors":"Rgj van der Zwet, E A Koemans, S Voigt, R van Dort, I Rasing, K Kaushik, T W van Harten, M R Schipper, G M Terwindt, Mjp van Osch, Maa van Walderveen, E S van Etten, Mjh Wermer","doi":"10.1177/17474930241239801","DOIUrl":"10.1177/17474930241239801","url":null,"abstract":"<p><strong>Background and aim: </strong>The revised Boston criteria v2.0 for cerebral amyloid angiopathy (CAA) add two radiological markers to the existing criteria: severe visible perivascular spaces in the centrum semiovale and white matter hyperintensities (WMHs) in a multispot pattern. This study aims to determine the sensitivity of the updated criteria in mutation carriers with Dutch-type hereditary CAA (D-CAA) in an early and later disease stage.</p><p><strong>Methods: </strong>In this cross-sectional study, we included presymptomatic and symptomatic D-CAA mutation carriers from our prospective natural history study (AURORA) at the Leiden University Medical Center between 2018 and 2021. 3-Tesla scans were assessed for CAA-related magnetic resonance imaging (MRI) markers. We compared the sensitivity of the Boston criteria v2.0 to the previously used modified Boston criteria v1.5.</p><p><strong>Results: </strong>We included 64 D-CAA mutation carriers (mean age 49 years, 55% women, 55% presymptomatic). At least one white matter (WM) feature was seen in 55/64 mutation carriers (86%: 74% presymptomatic, 100% symptomatic). Fifteen (23%) mutation carriers, all presymptomatic, showed only WM features and no hemorrhagic markers. The sensitivity for probable CAA was similar between the new and the previous criteria: 11/35 (31%) in presymptomatic mutation carriers and 29/29 (100%) in symptomatic mutation carriers. The sensitivity for possible CAA in presymptomatic mutation carriers increased from 0/35 (0%) to 15/35 (43%) with the new criteria.</p><p><strong>Conclusion: </strong>The Boston criteria v2.0 increase the sensitivity for detecting possible CAA in presymptomatic D-CAA mutation carriers and, therefore, improve the detection of the early phase of CAA.</p>","PeriodicalId":14442,"journal":{"name":"International Journal of Stroke","volume":null,"pages":null},"PeriodicalIF":6.3,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11408943/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140039366","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Clinical impact of body mass index on outcomes of ischemic and hemorrhagic strokes. 体重指数对缺血性和出血性脑卒中预后的临床影响。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-05-06 DOI: 10.1177/17474930241249370
Kaori Miwa, Michikazu Nakai, Sohei Yoshimura, Yusuke Sasahara, Shinichi Wada, Junpei Koge, Akiko Ishigami, Yoshiki Yagita, Kenji Kamiyama, Yoshihiro Miyamoto, Shotai Kobayashi, Kazuo Minematsu, Kazunori Toyoda, Masatoshi Koga

Background and aim: To investigate the prognostic implication of body mass index (BMI) on clinical outcomes after acute ischemic and hemorrhagic stroke.

Methods: The subjects of the study included adult patients with available baseline body weight and height data who had suffered an acute stroke and were registered in the Japan Stroke Data Bank-a hospital-based, multicenter stroke registration database-between January 2006 and December 2020. The outcome measures included unfavorable outcomes defined as a modified Rankin Scale (mRS) score of 5-6 and favorable outcomes (mRS 0-2) at discharge, and in-hospital mortality. Mixed effects logistic regression analysis was conducted to determine the relationship between BMI categories (underweight, normal weight, overweight, class I obesity, class II obesity; <18.5, 18.5-23.0, 23.0-25.0, 25-30, ⩾30 kg/m2) and the outcomes, after adjustment for covariates.

Results: A total of 56,230 patients were assigned to one of the following groups: ischemic stroke (IS, n = 43,668), intracerebral hemorrhage (ICH, n = 9741), and subarachnoid hemorrhage (SAH, n = 2821). In the IS group, being underweight was associated with an increased likelihood of unfavorable outcomes (odds ratio, 1.47 (95% confidence interval (CI):1.31-1.65)) and in-hospital mortality (1.55 (1.31-1.83)) compared to outcomes in those with normal weight. Being overweight was associated with an increased likelihood of favorable outcomes (1.09 (1.01-1.18)). Similar associations were observed between underweight and these outcomes in specific IS subtypes (cardioembolic stroke, large artery stroke, and small-vessel occlusion). Patients with a BMI ⩾30.0 kg/m2 was associated with an increased likelihood of unfavorable outcomes (1.44 (1.01-2.17)) and in-hospital mortality (2.42 (1.26-4.65)) in large artery stroke. In patients with ICH, but not those with SAH, being underweight was associated with an increased likelihood of unfavorable outcomes (1.41 (1.01-1.99)).

Conclusions: BMI substantially impacts functional outcomes following IS and ICH. Lower BMI consistently affected post-stroke disability and mortality, while higher BMI values similarly affected these outcomes after large artery stroke.

背景和目的:研究体重指数(BMI)对急性缺血性和出血性脑卒中临床预后的影响:研究对象包括 2006 年 1 月至 2020 年 12 月期间在日本脑卒中数据库(Japan Stroke Data Bank)--一个基于医院的多中心脑卒中登记数据库--登记的急性脑卒中成年患者,这些患者均有体重和身高基线数据。结果测量包括出院时的不利结果(定义为改良Rankin量表(mRS)5-6分)、有利结果(mRS 0-2)和院内死亡率。在对协变量进行调整后,进行了混合效应逻辑回归分析,以确定体重指数类别(体重不足、正常体重、超重、I 级肥胖、II 级肥胖;2)与结果之间的关系:共有 56230 名患者被分配到以下组别:缺血性中风(IS,n = 43668)、脑内出血(ICH,n = 9741)和蛛网膜下腔出血(SAH,n = 2821)。在IS组中,与体重正常者的结果相比,体重过轻与不利结果(几率比1.47(95%置信区间(CI):1.31-1.65))和院内死亡率(1.55(1.31-1.83))的可能性增加有关。超重与有利结果的可能性增加有关(1.09 (1.01-1.18))。在特定的 IS 亚型(心栓塞性中风、大动脉中风和小血管闭塞)中,也观察到体重不足与这些结果之间存在类似的关联。在大动脉卒中中,BMI ⩾30.0 kg/m2 的患者出现不良预后(1.44 (1.01-2.17))和院内死亡率(2.42 (1.26-4.65))的可能性增加。在 ICH 患者中,体重过轻与不良预后的可能性增加(1.41 (1.01-1.99))相关,但与 SAH 患者无关:结论:体重指数对IS和ICH后的功能预后有很大影响。结论:体重指数对 IS 和 ICH 后的功能预后有很大影响。体重指数越低,中风后的残疾率和死亡率越高,而体重指数越高,大动脉中风后的这些预后也会受到类似影响。
{"title":"Clinical impact of body mass index on outcomes of ischemic and hemorrhagic strokes.","authors":"Kaori Miwa, Michikazu Nakai, Sohei Yoshimura, Yusuke Sasahara, Shinichi Wada, Junpei Koge, Akiko Ishigami, Yoshiki Yagita, Kenji Kamiyama, Yoshihiro Miyamoto, Shotai Kobayashi, Kazuo Minematsu, Kazunori Toyoda, Masatoshi Koga","doi":"10.1177/17474930241249370","DOIUrl":"10.1177/17474930241249370","url":null,"abstract":"<p><strong>Background and aim: </strong>To investigate the prognostic implication of body mass index (BMI) on clinical outcomes after acute ischemic and hemorrhagic stroke.</p><p><strong>Methods: </strong>The subjects of the study included adult patients with available baseline body weight and height data who had suffered an acute stroke and were registered in the Japan Stroke Data Bank-a hospital-based, multicenter stroke registration database-between January 2006 and December 2020. The outcome measures included unfavorable outcomes defined as a modified Rankin Scale (mRS) score of 5-6 and favorable outcomes (mRS 0-2) at discharge, and in-hospital mortality. Mixed effects logistic regression analysis was conducted to determine the relationship between BMI categories (underweight, normal weight, overweight, class I obesity, class II obesity; <18.5, 18.5-23.0, 23.0-25.0, 25-30, ⩾30 kg/m<sup>2</sup>) and the outcomes, after adjustment for covariates.</p><p><strong>Results: </strong>A total of 56,230 patients were assigned to one of the following groups: ischemic stroke (IS, n = 43,668), intracerebral hemorrhage (ICH, n = 9741), and subarachnoid hemorrhage (SAH, n = 2821). In the IS group, being underweight was associated with an increased likelihood of unfavorable outcomes (odds ratio, 1.47 (95% confidence interval (CI):1.31-1.65)) and in-hospital mortality (1.55 (1.31-1.83)) compared to outcomes in those with normal weight. Being overweight was associated with an increased likelihood of favorable outcomes (1.09 (1.01-1.18)). Similar associations were observed between underweight and these outcomes in specific IS subtypes (cardioembolic stroke, large artery stroke, and small-vessel occlusion). Patients with a BMI ⩾30.0 kg/m<sup>2</sup> was associated with an increased likelihood of unfavorable outcomes (1.44 (1.01-2.17)) and in-hospital mortality (2.42 (1.26-4.65)) in large artery stroke. In patients with ICH, but not those with SAH, being underweight was associated with an increased likelihood of unfavorable outcomes (1.41 (1.01-1.99)).</p><p><strong>Conclusions: </strong>BMI substantially impacts functional outcomes following IS and ICH. Lower BMI consistently affected post-stroke disability and mortality, while higher BMI values similarly affected these outcomes after large artery stroke.</p>","PeriodicalId":14442,"journal":{"name":"International Journal of Stroke","volume":null,"pages":null},"PeriodicalIF":6.3,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11408962/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140849453","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Associated demographic factors for the recurrence and prognosis of stroke patients within a multiethnic Asian population. 多种族亚裔人群中脑卒中患者复发和预后的相关人口学因素。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-06-06 DOI: 10.1177/17474930241257759
Keng Siang Lee, Isabel Siow, Tessa Riandini, Kaavya Narasimhalu, Kelvin Bryan Tan, Deidre Anne De Silva

Objective: There is a paucity of studies investigating the outcomes among Asian stroke patients. Identifying subgroups of stroke patients at risk of poorer outcomes could identify patients who would benefit from targeted interventions. Therefore, the aim of this study was to identify which ischemic stroke patients at high risk of recurrent events and mortality.

Methods: This cohort study adhered to STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines. We obtained data from the Singapore Stroke Registry (SSR) from 2005 to 2016 and cross referenced to the Death Registry and the Myocardial Infarction Registry. Outcome measures included recurrent stroke, acute myocardial infarction (AMI), and all-cause and stroke-related deaths. Multivariable Cox proportional hazards regression models were performed to determine risk factors for recurrent stroke, AMI, and all-cause and stroke-related deaths.

Results: A total of 64,915 patients (6705 young, and 58,210 older) were included in our analysis. Older stroke patients were found to have an increased risk of recurrent stroke (hazard ratio (HR) = 1.21, 95% confidence interval (CI) = 1.12-1.30), AMI (HR = 1.73, 95% CI = 1.54-1.95), all-cause death (HR = 2.49, 95% CI = 2.34-2.64), and stroke-related death (HR = 176, 95% CI = 1.61-1.92). Among young stroke patients, males were at increased risk for recurrent stroke (HR = 1.18, 95% CI = 1.01-1.39) and AMI (HR = 1.41, 95% CI = 1.08-1.83), but at reduced risk for all-cause (HR = 0.78, 95% CI = 0.69-0.89) and stroke-related deaths (HR = 0.79, 95% CI = 0.67-0.94). Ethnicity appeared to influence outcomes, with Malay patients at increased risk of recurrent stroke (HR = 1.37, 95% CI = 1.14-1.65), AMI (HR = 2.45, 95% CI = 1.87-3.22), and all-cause (HR = 1.43, 95% CI = 1.24-1.66) and stroke-related deaths (HR = 1.34, 95% CI = 1.09-1.64). Indian patients were also at increased risk of AMI (HR = 1.96, 95% CI = 1.41-2.72). Similar findings were seen among the older stroke patients.

Conclusion: This study found that older stroke patients are at risk of poorer outcomes. Within the young stroke population specifically, males were predisposed to recurrent stroke and AMI but were protected against all-cause and stroke-related deaths. Males were also at reduced risk of all-cause and stroke-related deaths in the older stroke population. In addition, Malay and Indian patients experience poorer outcomes after first stroke. Further optimization of risk factors targeting these high-priority populations are needed to achieve high-quality care.

目的:有关亚裔中风患者预后的研究很少。识别有较差预后风险的中风患者亚群可确定哪些患者可从有针对性的干预措施中获益。因此,本研究旨在确定哪些缺血性脑卒中患者有复发和死亡的高风险:这项队列研究遵循了《加强流行病学观察性研究的报告》(STrengthening the Reporting of OBservational studies in Epidemiology,STROBE)指南。我们从新加坡卒中登记处(SSR)获得了 2005 年至 2016 年的数据,并与死亡登记处、心肌梗死登记处进行了交叉比对。结果指标包括复发性卒中、急性心肌梗死(AMI)、全因死亡和卒中相关死亡。采用多变量考克斯比例危险回归模型确定复发性中风、急性心肌梗死、全因和中风相关死亡的风险因素:共有 64,915 名患者(6,705 名年轻患者和 58,210 名老年患者)纳入了我们的分析。发现老年中风患者复发中风(HR = 1.21,95%CI:1.12-1.30)、急性心肌梗死(HR = 1.73,95%CI:1.54-1.95)、全因死亡(HR = 2.49,95%CI:2.34-2.64)和中风相关死亡(HR = 176,95%CI:1.61-1.92)的风险增加。在年轻脑卒中患者中,男性复发脑卒中(HR = 1.18,95%CI:1.01-1.39)和急性心肌梗死(HR = 1.41,95%CI:1.08-1.83)的风险增加,但全因(HR = 0.78,95%CI:0.69-0.89)和脑卒中相关死亡(HR = 0.79,95%CI:0.67-0.94)的风险降低。种族似乎对预后有影响,马来患者复发中风(HR = 1.37,95%CI:1.14-1.65)、AMI(HR = 2.45,95%CI:1.87-3.22)、全因(HR = 1.43,95%CI:1.24-1.66)和中风相关死亡(HR = 1.34,95%CI:1.09-1.64)的风险增加。印度患者发生急性心肌梗死的风险也有所增加(HR = 1.96,95%CI:1.41-2.72)。在老年中风患者中也有类似发现:本研究发现,老年脑卒中患者的预后风险较低。特别是在年轻中风人群中,男性易患中风复发和急性心肌梗死,但可避免全因死亡和中风相关死亡。在老年中风人群中,男性全因死亡和中风相关死亡的风险也有所降低。此外,马来和印度患者在首次中风后的预后较差。需要针对这些高危人群进一步优化风险因素,以实现高质量的医疗服务。
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引用次数: 0
Endovascular treatment to improve outcomes for medium vessel occlusions: The ESCAPE-MeVO trial. 改善中血管闭塞预后的血管内治疗:ESCAPE-MeVO试验。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-06-20 DOI: 10.1177/17474930241262642
Johanna M Ospel, Dar Dowlatshahi, Andrew Demchuk, David Volders, Markus Möhlenbruch, Shahid Nimjee, James Kennedy, Brian Buck, Jai Jai Shankar, Thomas C Booth, Mouhammad A Jumaa, Robert Fahed, Aravind Ganesh, Qiao Zhang, Craig Doram, Karla J Ryckborst, Michael D Hill, Mayank Goyal
<p><strong>Rationale: </strong>Clinical outcomes in acute ischemic stroke due to medium vessel occlusion (MeVO) are often poor when treated with best medical management. Data from non-randomized studies suggest that endovascular treatment (EVT) may improve outcomes in MeVO stroke, but randomized data on potential benefits and risks are hitherto lacking. Thus, there is insufficient evidence to guide EVT decision-making in MeVO stroke.</p><p><strong>Aims: </strong>The primary aim of the ESCAPE-MeVO trial is to demonstrate that acute, rapid EVT in patients with acute ischemic stroke due to MeVO results in better clinical outcomes compared to best medical management. Secondary outcomes are to demonstrate the safety of EVT, its impact on self-reported health-related quality of life, and cost-effectiveness.</p><p><strong>Sample size estimates: </strong>Based on previously published data, we estimate a sample size of 500 subjects to achieve a power of 85% with a two-sided alpha of 0.05. To account for potential loss to follow-up, 530 subjects will be recruited.</p><p><strong>Methods and design: </strong>ESCAPE-MeVO is a multicenter, prospective, randomized, open-label study with blinded endpoint evaluation (PROBE design), clinicaltrials.gov: NCT05151172. Subjects with acute ischemic stroke due to MeVO meeting the trial eligibility criteria will be allocated in a 1:1 ratio to best medical care plus EVT versus best medical care only. Patients will be screened only at comprehensive stroke centers to determine if they are eligible for the trial, regardless of whether they were previously treated at a primary care center. Key eligibility criteria are (1) acute ischemic stroke due to MeVO that is clinically and technically eligible for EVT, (2) last-known well within the last 12 h, (3) National Institutes of Health Stroke Scale > 5 or 3-5 with disabling deficit, (4) high likelihood of salvageable tissue on non-invasive neuroimaging.</p><p><strong>Study outcomes: </strong>The primary outcome is the modified Rankin scale 90 days after randomization (shift analysis), whereby modified Rankin Score 5 and 6 will be collapsed into one category. Secondary outcomes include dichotomizations of the modified Rankin Score at 90 days, 24 h National Institutes of Health Stroke Score, difference between 24 h and baseline National Institutes of Health Stroke Score, mortality at 90 days, health-related quality of life (EQ-5D-5 L), Lawton scale of instrumental activities of daily living score, reperfusion quality (MeVO expanded Thrombolysis in Cerebral Infarction Score) and infarct volume at 24 h, and cost-effectiveness of endovascular recanalization. Safety outcomes include symptomatic and asymptomatic intracranial hemorrhage and procedural complications.</p><p><strong>Discussion: </strong>The ESCAPE-MeVO trial will demonstrate the effect of endovascular thrombectomy in addition to best medical management vis-à-vis best medical management in patients with acute ischemic stroke
理由:中血管闭塞(MeVO)导致的急性缺血性卒中在接受最佳药物治疗后,临床疗效往往不佳。非随机研究数据表明,血管内治疗(EVT)可改善中血管闭塞性卒中的预后,但迄今为止尚缺乏有关潜在益处和风险的随机数据。目的:ESCAPE-MeVO 试验的主要目的是证明对 MeVO 引起的急性缺血性卒中患者进行急性、快速 EVT 与最佳内科治疗相比可获得更好的临床疗效。次要结果是证明 EVT 的安全性、对自我报告的健康相关生活质量的影响以及成本效益:根据之前公布的数据,我们估计样本量为 500 名受试者,双侧α值为 0.05 时的功率为 85%。考虑到可能的随访损失,我们将招募 530 名受试者:ESCAPE-MeVO是一项多中心、前瞻性、随机、开放标签研究,采用盲法终点评估(PROBE设计),clinicaltrials.gov:NCT05151172。符合试验资格标准的 MeVO 急性缺血性脑卒中受试者将按 1:1 的比例分配到最佳医疗加 EVT 与仅最佳医疗中。患者将只在综合卒中中心接受筛查,以确定其是否符合试验条件,无论其之前是否在初级医疗中心接受过治疗。主要资格标准为:1)因MeVO导致的急性缺血性卒中,临床和技术上均符合EVT治疗条件;2)在过去12小时内最后一次获知病情;3)美国国立卫生研究院卒中量表>5或3-5,伴有致残性缺损;4)在非侵入性神经影像学检查中发现可挽救组织的可能性很高:主要结果是随机分组 90 天后的改良 Rankin 评分(移位分析),其中改良 Rankin 评分 5 分和 6 分将合并为一类。次要结果包括:90天时的改良Rankin评分的二分法、24小时美国国立卫生研究院卒中评分、24小时美国国立卫生研究院卒中评分与基线美国国立卫生研究院卒中评分之间的差异、90天时的死亡率、健康相关生活质量(EQ-5D-5L)、Lawton日常生活工具活动评分、24小时时的再灌注质量(MeVO扩大脑梗塞溶栓评分)和梗塞体积,以及血管内再通的成本效益。安全性结果包括无症状和无症状颅内出血以及手术并发症:ESCAPE-MeVO试验将证明在最佳内科治疗的基础上进行血管内血栓切除术与最佳内科治疗相比,对MeVO引起的急性缺血性卒中患者的效果,并为急性MeVO卒中的循证治疗决策提供数据。
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International Journal of Stroke
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