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Regional disparities in prehospital delay of acute ischemic stroke: The Korean Stroke Registry. 急性缺血性脑卒中院前延误的地区差异:韩国卒中登记
IF 5.8 3区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-12-01 Epub Date: 2024-05-17 DOI: 10.1177/23969873241253670
Eung-Joon Lee, Han-Yeong Jeong, Jayoun Kim, Nan Hee Park, Min Kyoung Kang, Dongwhane Lee, Jinkwon Kim, Yo Han Jung, Sungwook Yu, Wook-Joo Kim, Han-Jin Cho, Kyungbok Lee, Tai Hwan Park, Mi Sun Oh, Ji Sung Lee, Joon-Tae Kim, Byung-Woo Yoon, Jong-Moo Park, Hee-Joon Bae, Keun-Hwa Jung

Background: Late hospital arrival keeps patients with stroke from receiving recanalization therapy and is associated with poor outcomes. This study used a nationwide acute stroke registry to investigate the trends and regional disparities in prehospital delay and analyze the significant factors associated with late arrivals.

Methods: Patients with acute ischemic stroke or transient ischemic attack between January 2012 and December 2021 were included. The prehospital delay was identified, and its regional disparity was evaluated using the Gini coefficient for nine administrative regions. Multivariate models were used to identify factors significantly associated with prehospital delays of >4.5 h.

Results: A total of 144,014 patients from 61 hospitals were included. The median prehospital delay was 460 min (interquartile range, 116-1912), and only 36.8% of patients arrived at hospitals within 4.5 h. Long prehospital delays and high regional inequality (Gini coefficient > 0.3) persisted throughout the observation period. After adjusting for confounders, age > 65 years old (adjusted odds ratio [aOR] = 1.23; 95% confidence interval [CI], 1.19-1.27), female sex (aOR = 1.09; 95% CI, 1.05-1.13), hypertension (aOR = 1.12; 95% CI, 1.08-1.16), diabetes mellitus (aOR = 1.38; 95% CI, 1.33-1.43), smoking (aOR = 1.15, 95% CI, 1.11-1.20), premorbid disability (aOR = 1.44; 95% CI, 1.37-1.52), and mild stroke severity (aOR = 1.55; 95% CI, 1.50-1.61) were found to independently predict prehospital delays of >4.5 h.

Conclusion: Prehospital delays were lengthy and had not improved in Korea, and there was a high regional disparity. To overcome these inequalities, a deeper understanding of regional characteristics and further research is warranted to address the vulnerabilities identified.

背景:延迟到达医院会使卒中患者无法接受再通路治疗,并与不良预后相关。本研究利用一项全国性急性卒中登记研究,调查院前延误的趋势和地区差异,并分析与晚到相关的重要因素:方法:纳入 2012 年 1 月至 2021 年 12 月间急性缺血性卒中或短暂性脑缺血发作患者。方法:纳入 2012 年 1 月至 2021 年 12 月期间急性缺血性卒中或短暂性脑缺血发作患者,确定院前延误情况,并使用九个行政区域的基尼系数评估其地区差异。采用多变量模型确定与院前延误超过4.5小时显著相关的因素:结果:共纳入了 61 家医院的 144 014 名患者。院前延误的中位数为 460 分钟(四分位数间距为 116-1912 分),只有 36.8% 的患者在 4.5 小时内到达医院。在整个观察期间,院前延误时间长和地区不平等程度高(基尼系数大于 0.3)的现象持续存在。在对混杂因素进行调整后,年龄大于 65 岁(调整赔率 [aOR] = 1.23;95% 置信区间 [CI],1.19-1.27)、女性(aOR = 1.09;95% CI,1.05-1.13)、高血压(aOR = 1.12;95% CI,1.08-1.16)、糖尿病(aOR = 1.38;95% CI,1.33-1.43)、吸烟(aOR = 1.15,95% CI,1.11-1.20)、病前残疾(aOR = 1.44;95% CI,1.37-1.52)和轻度卒中严重程度(aOR = 1.55;95% CI,1.50-1.61)可独立预测院前延误超过 4.5 小时:结论:在韩国,院前延误的时间很长,而且没有得到改善,地区之间的差异也很大。为了克服这些不平等现象,有必要深入了解地区特点并开展进一步研究,以解决已发现的薄弱环节。
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引用次数: 0
Outcomes of mechanical thrombectomy in anticoagulated patients with acute distal and medium vessel stroke. 对急性远端和中血管卒中的抗凝患者进行机械血栓切除术的疗效。
IF 5.8 3区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-12-01 Epub Date: 2024-05-10 DOI: 10.1177/23969873241249295
Hamza Salim, Basel Musmar, Nimer Adeeb, Vivek Yedavalli, Dhairya Lakhani, Sahibjot Singh Grewal, Kareem El Naamani, Nils Henninger, Sri Hari Sundararajan, Anna Luisa Kühn, Jane Khalife, Sherief Ghozy, Luca Scarcia, Benjamin Yq Tan, Robert W Regenhardt, Jeremy J Heit, Nicole M Cancelliere, Joshua D Bernstock, Aymeric Rouchaud, Jens Fiehler, Sunil Sheth, Ajit S Puri, Christian Dyzmann, Marco Colasurdo, Xavier Barreau, Leonardo Renieri, João Pedro Filipe, Pablo Harker, Răzvan Alexandru Radu, Mohamad Abdalkader, Piers Klein, Thomas R Marotta, Julian Spears, Takahiro Ota, Ashkan Mowla, Pascal Jabbour, Arundhati Biswas, Frédéric Clarençon, James E Siegler, Thanh N Nguyen, Ricardo Varela, Amanda Baker, Muhammed Amir Essibayi, David Altschul, Nestor R Gonzalez, Markus A Möhlenbruch, Vincent Costalat, Benjamin Gory, Christian Paul Stracke, Mohammad Ali Aziz-Sultan, Constantin Hecker, Hamza Shaikh, David S Liebeskind, Alessandro Pedicelli, Andrea M Alexandre, Illario Tancredi, Tobias D Faizy, Erwah Kalsoum, Boris Lubicz, Aman B Patel, Vitor Mendes Pereira, Adrien Guenego, Adam A Dmytriw

Background: Stroke remains a major health concern globally, with oral anticoagulants widely prescribed for stroke prevention. The efficacy and safety of mechanical thrombectomy (MT) in anticoagulated patients with distal medium vessel occlusions (DMVO) are not well understood.

Methods: This retrospective analysis involved 1282 acute ischemic stroke (AIS) patients who underwent MT in 37 centers across North America, Asia, and Europe from September 2017 to July 2023. Data on demographics, clinical presentation, treatment specifics, and outcomes were collected. The primary outcomes were functional outcomes at 90 days post-MT, measured by modified Rankin Scale (mRS) scores. Secondary outcomes included reperfusion rates, mortality, and hemorrhagic complications.

Results: Of the patients, 223 (34%) were on anticoagulation therapy. Anticoagulated patients were older (median age 78 vs 74 years; p < 0.001) and had a higher prevalence of atrial fibrillation (77% vs 26%; p < 0.001). Their baseline National Institutes of Health Stroke Scale (NIHSS) scores were also higher (median 12 vs 9; p = 0.002). Before propensity score matching (PSM), anticoagulated patients had similar rates of favorable 90-day outcomes (mRS 0-1: 30% vs 37%, p = 0.1; mRS 0-2: 47% vs 50%, p = 0.41) but higher mortality (26% vs 17%, p = 0.008). After PSM, there were no significant differences in outcomes between the two groups.

Conclusion: Anticoagulated patients undergoing MT for AIS due to DMVO did not show significant differences in 90-day mRS outcomes, reperfusion, or hemorrhage compared to non-anticoagulated patients after adjustment for covariates.

背景:脑卒中仍然是全球关注的主要健康问题,口服抗凝剂被广泛用于预防脑卒中。机械性血栓切除术(MT)对抗凝血的远端中血管闭塞(DMVO)患者的疗效和安全性尚不十分清楚:这项回顾性分析涉及 2017 年 9 月至 2023 年 7 月期间在北美、亚洲和欧洲 37 个中心接受 MT 治疗的 1282 名急性缺血性卒中(AIS)患者。收集了有关人口统计学、临床表现、治疗细节和结果的数据。主要结果是MT术后90天的功能结果,以改良Rankin量表(mRS)评分来衡量。次要结果包括再灌注率、死亡率和出血并发症:患者中有 223 人(34%)接受了抗凝治疗。抗凝患者年龄较大(中位年龄 78 岁对 74 岁;P P = 0.002)。倾向评分匹配(PSM)前,抗凝患者的 90 天良好预后率相似(mRS 0-1:30% vs 37%,p = 0.1;mRS 0-2:47% vs 50%,p = 0.41),但死亡率较高(26% vs 17%,p = 0.008)。PSM 后,两组患者的预后无明显差异:结论:对协变量进行调整后,因 DMVO 而接受 MT 治疗的抗凝患者与非抗凝患者相比,在 90 天 mRS 结果、再灌注或出血方面没有显著差异。
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引用次数: 0
Timing of oral anticoagulants initiation for atrial fibrillation after acute ischemic stroke: A systematic review and meta-analysis. 急性缺血性脑卒中后心房颤动口服抗凝药的起始时机:系统回顾和荟萃分析。
IF 5.8 3区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-12-01 Epub Date: 2024-05-14 DOI: 10.1177/23969873241251931
Lina Palaiodimou, Maria-Ioanna Stefanou, Aristeidis H Katsanos, Gian Marco De Marchis, Diana Aguiar De Sousa, Jesse Dawson, Mira Katan, Theodore Karapanayiotides, Konstantinos Toutouzas, Maurizio Paciaroni, David J Seiffge, Georgios Tsivgoulis

Introduction: There is a longstanding clinical uncertainty regarding the optimal timing of initiating oral anticoagulants (OAC) for non-valvular atrial fibrillation following acute ischemic stroke. Current international recommendations are based on expert opinions, while significant diversity among clinicians is noted in everyday practice.

Methods: We conducted an updated systematic review and meta-analysis including all available randomized-controlled clinical trials (RCTs) and observational cohort studies that investigated early versus later OAC-initiation for atrial fibrillation after acute ischemic stroke. The primary outcome was defined as the composite of ischemic and hemorrhagic events and mortality at follow-up. Secondary outcomes included the components of the composite outcome (ischemic stroke recurrence, intracranial hemorrhage, major bleeding, and all-cause mortality). Pooled estimates were calculated with random-effects model.

Results: Nine studies (two RCTs and seven observational) were included comprising a total of 4946 patients with early OAC-initiation versus 4573 patients with later OAC-initiation following acute ischemic stroke. Early OAC-initiation was associated with reduced risk of the composite outcome (RR = 0.74; 95% CI:0.56-0.98; I2 = 46%) and ischemic stroke recurrence (RR = 0.64; 95% CI:0.43-0.95; I2 = 60%) compared to late OAC-initiation. Regarding safety outcomes, similar rates of intracranial hemorrhage (RR = 0.98; 95% CI:0.57-1.69; I2 = 21%), major bleeding (RR = 0.78; 95% CI:0.40-1.51; I2 = 0%), and mortality (RR = 0.94; 95% CI:0.61-1.45; I2 = 0%) were observed. There were no subgroup differences, when RCTs and observational studies were separately evaluated.

Conclusions: Early OAC-initiation in acute ischemic stroke patients with non-valvular atrial fibrillation appears to have better efficacy and a similar safety profile compared to later OAC-initiation.

导言:对于急性缺血性卒中后非瓣膜性心房颤动患者启动口服抗凝药(OAC)的最佳时机,临床上长期存在不确定性。目前国际上的建议是基于专家意见,而在日常实践中,临床医生之间存在很大差异:我们进行了一项最新的系统综述和荟萃分析,包括所有可用的随机对照临床试验(RCT)和观察性队列研究,这些研究调查了急性缺血性卒中后心房颤动早期启动 OAC 与晚期启动 OAC 的区别。主要结果定义为缺血性和出血性事件的复合结果以及随访时的死亡率。次要结局包括综合结局的各个组成部分(缺血性卒中复发、颅内出血、大出血和全因死亡率)。采用随机效应模型计算汇总估计值:共纳入 9 项研究(2 项研究性临床试验和 7 项观察性研究),包括急性缺血性卒中后早期启用 OAC 的 4946 例患者和晚期启用 OAC 的 4573 例患者。与晚期启用 OAC 相比,早期启用 OAC 可降低复合结局风险(RR = 0.74;95% CI:0.56-0.98;I2 = 46%)和缺血性卒中复发风险(RR = 0.64;95% CI:0.43-0.95;I2 = 60%)。在安全性方面,观察到的颅内出血率(RR = 0.98;95% CI:0.57-1.69;I2 = 21%)、大出血率(RR = 0.78;95% CI:0.40-1.51;I2 = 0%)和死亡率(RR = 0.94;95% CI:0.61-1.45;I2 = 0%)相似。对研究性试验和观察性研究分别进行评估后,没有发现亚组差异:结论:与晚期启动 OAC 相比,非瓣膜性心房颤动急性缺血性卒中患者早期启动 OAC 似乎具有更好的疗效和相似的安全性。
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引用次数: 0
Prehospital stroke diagnostics using three different simulation methods: A pragmatic pilot study. 使用三种不同模拟方法进行院前中风诊断:实用试点研究。
IF 5.8 3区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-12-01 Epub Date: 2024-05-16 DOI: 10.1177/23969873241252564
Emma Christensen, Helge Fagerheim Bugge, Jostein Hagemo, Karianne Larsen, Astrid Kv Harring, Jostein Gleditsch, Jørgen Ibsen, Mona Guterud, Else Charlotte Sandset, Maren Ranhoff Hov

Introduction: The optimal pathway for ultra-early diagnostics and treatment in patients with acute stroke remains uncertain. The aim of this study was to investigate how three different methods of simulated, rural prehospital computed tomography (CT) affected the time to prehospital treatment decision in acute stroke.

Materials and methods: In this pragmatic, simulation, pilot study of prehospital CT we investigated a conventional ambulance with transport to a standard care rural stationary CT machine managed by paramedics, a Mobile Stroke Unit (MSU), and a helicopter with a simulated CT machine. Each modality completed 20 real-life dispatches combined with simulation of predetermined animated patient cases with acute stroke symptoms and CT images. The primary endpoint of the study was the time from alarm to treatment decision.

Results: Median time from alarm to the treatment decision differed significantly between the three groups (p = 0.0005), with 38 min for rural CT, 33 min for the MSU, and 30 min for the helicopter. There was no difference in time when comparing rural CT with MSU, nor when comparing the MSU with the helicopter. There was a difference in time to treatment decision between the rural CT and the helicopter (p < 0.0001). The helicopter had significantly lower estimated time from treatment decision to hospital (p = 0.001).

Disscussion/conclusion: Prehospital CT can be organized in several ways depending on geography, resources and need. Further research on paramedic run rural CT, MSU in rural areas, and helicopter CT is needed to find the optimal strategy.

导言:急性中风患者超早期诊断和治疗的最佳途径仍不确定。本研究旨在调查三种不同的模拟农村院前计算机断层扫描(CT)方法如何影响急性中风患者的院前治疗决策时间:在这项实用的院前 CT 模拟试点研究中,我们调查了由医护人员管理的传统救护车、移动卒中单元(MSU)和配备模拟 CT 机的直升机运送标准护理农村固定 CT 机的情况。每种模式都完成了 20 次真实调度,同时模拟了具有急性中风症状和 CT 图像的预定动画患者病例。研究的主要终点是从报警到做出治疗决定的时间:从报警到做出治疗决定的中位时间在三组之间存在显著差异(p = 0.0005),农村 CT 为 38 分钟,MSU 为 33 分钟,直升机为 30 分钟。农村 CT 与 MSU 相比,时间没有差异;MSU 与直升机相比,时间也没有差异。农村 CT 和直升机在做出治疗决定的时间上存在差异(P = 0.001):院前 CT 可根据地理位置、资源和需求以多种方式组织。需要进一步研究由护理人员管理的农村 CT、农村地区的 MSU 和直升机 CT,以找到最佳策略。
{"title":"Prehospital stroke diagnostics using three different simulation methods: A pragmatic pilot study.","authors":"Emma Christensen, Helge Fagerheim Bugge, Jostein Hagemo, Karianne Larsen, Astrid Kv Harring, Jostein Gleditsch, Jørgen Ibsen, Mona Guterud, Else Charlotte Sandset, Maren Ranhoff Hov","doi":"10.1177/23969873241252564","DOIUrl":"10.1177/23969873241252564","url":null,"abstract":"<p><strong>Introduction: </strong>The optimal pathway for ultra-early diagnostics and treatment in patients with acute stroke remains uncertain. The aim of this study was to investigate how three different methods of simulated, rural prehospital computed tomography (CT) affected the time to prehospital treatment decision in acute stroke.</p><p><strong>Materials and methods: </strong>In this pragmatic, simulation, pilot study of prehospital CT we investigated a conventional ambulance with transport to a standard care rural stationary CT machine managed by paramedics, a Mobile Stroke Unit (MSU), and a helicopter with a simulated CT machine. Each modality completed 20 real-life dispatches combined with simulation of predetermined animated patient cases with acute stroke symptoms and CT images. The primary endpoint of the study was the time from alarm to treatment decision.</p><p><strong>Results: </strong>Median time from alarm to the treatment decision differed significantly between the three groups (<i>p</i> = 0.0005), with 38 min for rural CT, 33 min for the MSU, and 30 min for the helicopter. There was no difference in time when comparing rural CT with MSU, nor when comparing the MSU with the helicopter. There was a difference in time to treatment decision between the rural CT and the helicopter (<i>p</i> < 0.0001). The helicopter had significantly lower estimated time from treatment decision to hospital (<i>p</i> = 0.001).</p><p><strong>Disscussion/conclusion: </strong>Prehospital CT can be organized in several ways depending on geography, resources and need. Further research on paramedic run rural CT, MSU in rural areas, and helicopter CT is needed to find the optimal strategy.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":" ","pages":"1016-1024"},"PeriodicalIF":5.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11569525/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140946123","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"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
Acute astrocytic reaction is associated with 3-month functional outcome after stroke treated with endovascular therapy. 急性星形胶质细胞反应与血管内治疗脑卒中后 3 个月的功能预后有关。
IF 5.8 3区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-12-01 Epub Date: 2024-06-06 DOI: 10.1177/23969873241256813
Ada Boutelier, Véronique Ollivier, Mikael Mazighi, Maeva Kyheng, Julien Labreuche, Nahida Brikci-Nigassa, Mialitiana Solo Nomenjanahary, Francois Delvoye, Benjamin Maier, Claire Paquet, Benoit Ho-Tin-Noe, Jean-Philippe Desilles

Introduction: More than 50% of large vessel occlusion (LVO) acute ischemic stroke (AIS) patients treated with endovascular therapy (EVT) remain severely disabled at 3 months. We hypothesized that acute astrocytic inflammatory response may play a pivotal role in post-AIS brain changes associated with poor functional outcome. We proposed to evaluate the level of YKL-40, a glycoprotein mainly released by reactive astrocytes.

Patients and methods: A monocentric prospective cohort study was conducted on consecutive LVO AIS patients treated with EVT. Three blood samples (before, within 1 and 24-hour post-EVT) were collected to measure plasma YKL-40 concentrations. Functional outcome was assessed according to the modified Rankin Scale (mRS) score at 3 months.

Results: Between 2016 and 2020, 120 patients were included. The plasma concentration of YKL-40 before EVT was statistically and independently associated with 3-month worse functional outcome (adjusted cOR, 1.59; 95% CI [1.05-2.44], p = 0.027) but not the two following samples 1-hour and 24-hour post-EVT. Accordingly, we found that excellent functional outcome was associated with a lower level of YKL-40 before and within 1 h after EVT (p = 0.005 and p = 0.003, respectively) but not when measured 24 h after EVT (p = 0.2).

Discussion and conclusion: This study suggests that the astrocytic reaction to acute brain hypoxia, especially before recanalization, is associated with worse functional outcome. Such early biomarker of the astrocytic response in AIS may optimize individualized care in the future.

Clinical trial registration-url: http://www.clinicaltrials.gov. Unique identifier: NCT02900833.

导言:在接受血管内治疗(EVT)的大血管闭塞(LVO)急性缺血性脑卒中(AIS)患者中,超过 50%的患者在 3 个月后仍然严重残疾。我们推测,急性星形胶质细胞炎症反应可能在与不良功能预后相关的 AIS 后脑部变化中起着关键作用。我们提议评估YKL-40的水平,这是一种主要由反应性星形胶质细胞释放的糖蛋白:对连续接受 EVT 治疗的 LVO AIS 患者进行了单中心前瞻性队列研究。收集了三次血液样本(EVT前、EVT后1小时内和24小时内),以测量血浆中YKL-40的浓度。根据3个月后的改良Rankin量表(mRS)评分评估功能预后:结果:2016年至2020年间,共纳入120名患者。EVT前的血浆YKL-40浓度与3个月后较差的功能预后有统计学上的独立相关性(调整后的cOR,1.59;95% CI [1.05-2.44],p = 0.027),但与EVT后1小时和24小时后的两个样本无关。因此,我们发现良好的功能预后与EVT前和EVT后1小时内较低的YKL-40水平相关(分别为p = 0.005和p = 0.003),但与EVT后24小时的测量结果无关(p = 0.2):本研究表明,星形胶质细胞对急性脑缺氧的反应,尤其是在再通之前,与较差的功能预后有关。这种AIS星形胶质细胞反应的早期生物标志物可优化未来的个体化治疗。临床试验注册-url:http://www.clinicaltrials.gov。唯一标识符:NCT02900833。
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引用次数: 0
Regarding the ESO guideline on the diagnosis and management of patent foramen ovale after stroke: Is it a matter of urgency? ESO关于卒中后卵圆孔未闭的诊断和管理指南:是否刻不容缓?
IF 5.8 3区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-12-01 Epub Date: 2024-08-02 DOI: 10.1177/23969873241265020
Christian H Nolte, Heinrich J Audebert
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引用次数: 0
The volume of steal phenomenon is associated with neurological deterioration in patients with large-vessel occlusion minor stroke not eligible for thrombectomy. 对于不符合血栓切除术条件的大血管闭塞性轻微脑卒中患者,盗血现象的体积与神经功能恶化有关。
IF 5.8 3区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-12-01 Epub Date: 2024-05-14 DOI: 10.1177/23969873241251718
Jacopo Bellomo, Martina Sebök, Christiaan Hb van Niftrik, Vittorio Stumpo, Tilman Schubert, Jawid Madjidyar, Patrick Thurner, Christoph Globas, Susanne Wegener, Andreas R Luft, Zsolt Kulcsár, Luca Regli, Jorn Fierstra

Introduction: A significant number of patients who present with mild symptoms following large-vessel occlusion acute ischemic stroke (LVO-AIS) are currently considered ineligible for EVT. However, they frequently experience neurological deterioration during hospitalization. This study aimed to investigate the association between neurological deterioration and hemodynamic impairment by assessing steal phenomenon derived from blood oxygenation-level dependent cerebrovascular reactivity (BOLD-CVR) in this specific patient cohort.

Patients and methods: From the database of our single-center BOLD-CVR observational cohort study (June 2015-October 2023) we retrospectively identified acute ischemic stroke patients with admission NIHSS < 6, a newly detected large vessel occlusion of the anterior circulation and ineligible for EVT. Neurological deterioration during hospitalization as well as outcome at hospital discharge were rated with NIHSS score. We analyzed the association between these two outcomes and BOLD-CVR-derived steal phenomenon volume through regression analysis. Additionally, we investigated the discriminatory accuracy of steal phenomenon volume for predicting neurological deterioration.

Results: Forty patients were included in the final analysis. Neurological deterioration occurred in 35% of patients. In the regression analysis, a strong association between steal phenomenon volume and neurological deterioration (OR 4.80, 95% CI 1.32-31.04, p = 0.04) as well as poorer NIHSS score at hospital discharge (OR 3.73, 95% CI 1.52-10.78, p = 0.007) was found. The discriminatory accuracy of steal phenomenon for neurological deterioration prediction had an AUC of 0.791 (95% CI 0.653-0.930).

Discussion: Based on our results we may distinguish two groups of patients with minor stroke currently ineligible for EVT, however, showing hemodynamic impairment and exhibiting neurological deterioration during hospitalization: (1) patients exhibiting steal phenomenon on BOLD-CVR imaging as well as hemodynamic impairment on resting perfusion imaging; (2) patients exhibiting steal phenomenon on BOLD-CVR imaging, however, no relevant hemodynamic impairment on resting perfusion imaging.

Conclusion: The presence of BOLD-CVR derived steal phenomenon may aid to further study hemodynamic impairment in patients with minor LVO-AIS not eligible for EVT.

导言:大血管闭塞性急性缺血性卒中(LVO-AIS)后出现轻微症状的大量患者目前被认为不符合接受 EVT 的条件。然而,他们在住院期间经常出现神经功能恶化。本研究旨在通过评估这一特殊患者群体的血氧水平依赖性脑血管反应性(BOLD-CVR)得出的窃取现象,研究神经功能恶化与血液动力学损伤之间的关联:从我们的单中心 BOLD-CVR 观察性队列研究(2015 年 6 月至 2023 年 10 月)数据库中,我们回顾性地确定了急性缺血性卒中患者的入院 NIHSS 结果:40名患者纳入最终分析。35%的患者出现神经功能恶化。在回归分析中发现,盗血现象体积与神经功能恶化(OR 4.80,95% CI 1.32-31.04,p = 0.04)以及出院时 NIHSS 评分较差(OR 3.73,95% CI 1.52-10.78,p = 0.007)之间存在密切联系。偷窃现象对神经功能恶化预测的判别准确性的AUC为0.791(95% CI 0.653-0.930):讨论:根据我们的研究结果,我们可以将目前不符合EVT条件,但在住院期间出现血液动力学损伤并表现出神经功能恶化的轻微卒中患者分为两类:(1)BOLD-CVR成像显示盗血现象,静息灌注成像显示血液动力学损伤的患者;(2)BOLD-CVR成像显示盗血现象,但静息灌注成像没有相关血液动力学损伤的患者:结论:BOLD-CVR 导出的盗血现象有助于进一步研究不符合 EVT 条件的轻度 LVO-AIS 患者的血流动力学损伤。
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引用次数: 0
European Stroke Organisation and European Society for Minimally Invasive Neurological Therapy guideline on acute management of basilar artery occlusion. 欧洲脑卒中组织(ESO)和欧洲微创神经治疗学会(ESMINT)基底动脉闭塞症急性治疗指南。
IF 5.8 3区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-12-01 Epub Date: 2024-07-22 DOI: 10.1177/23969873241257223
Daniel Strbian, Georgios Tsivgoulis, Johanna Ospel, Silja Räty, Petra Cimflova, Georgios Georgiopoulos, Teresa Ullberg, Caroline Arquizan, Jan Gralla, Kamil Zeleňák, Salman Hussain, Jens Fiehler, Patrik Michel, Guillaume Turc, Wim Van Zwam
<p><p>The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology. Although BAO accounts for only 1%-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five ESMINT) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements. First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (albeit in small numbers) in IVT trials. Non-randomised studies of IVT-only cohorts showed high proportion of favourable outcomes. Expert Consensus suggests using IVT up to 24 h unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared to BMT alone within 6 and 6-24 h from last seen well. In both time windows, we observed a different effect of treatment depending on (a) the region where the patients were treated (Europe vs. Asia), (b) on the proportion of IVT in the BMT arm, and (c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with NIHSS below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT + BMT over BMT alone (i.e. based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT + BMT over BMT alone in proximal and middle locations of BAO compared to distal location. While recommendations for patients without extensive early ischaemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischaemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certai
本欧洲卒中组织(ESO)指南旨在为基底动脉闭塞(BAO)患者的急性期治疗提供循证建议。虽然基底动脉闭塞症仅占所有脑卒中的 1-2%,但其自然预后极差。我们确定了 10 种相关的临床情况,并制定了相应的人群干预比较结果 (PICO) 问题,在此基础上进行了系统的文献检索和综述。工作组由 10 名有投票权的成员(5 名代表 ESO,5 名代表 ESMINT)和 3 名无投票权的初级成员组成。证据的确定性普遍很低。首先,我们比较了静脉溶栓(IVT)和不静脉溶栓,但具体的 BAO 相关数据并不存在。然而,从历史上看,静脉溶栓是 BAO 患者的标准治疗方法,这些患者也被纳入静脉溶栓试验(尽管人数很少)。对仅进行 IVT 的队列进行的非随机研究显示,取得良好疗效的比例很高。专家共识建议,除非有其他禁忌症,IVT 的使用时间应长达 24 小时。我们还建议 IVT 加上血管内治疗 (EVT),而不是直接 EVT。我们将最佳药物治疗(BMT)基础上的 EVT 与最后一次见好后 6 小时内和 6-24 小时内的单纯 BMT 进行了比较。在这两个时间窗口中,我们观察到不同的治疗效果取决于:a) 患者接受治疗的地区(欧洲与亚洲);b) BMT 治疗组中 IVT 的比例;c) 最初中风的严重程度。在 BMT 组中 IVT 比例较高且 NIHSS 低于 10 的患者中,EVT 加 BMT 的效果并不比单用 BMT 好。基于极低的证据确定性,我们建议 EVT+BMT 优于单用 BMT(这是基于 NIHSS 至少为 10 分且 BMT 中 IVT 比例较低的患者的结果)。对于 NIHSS 低于 10 分的患者,我们没有发现建议 EVT 优于 BMT 的证据。事实上,BMT 比 EVT 的疗效和安全性均无显著性差异。此外,我们还发现,在 BAO 的近端和中间位置,EVT+BMT 的治疗效果要强于单纯 BMT。虽然对后窝无广泛早期缺血病变的患者的建议一般可遵循其他 PICOs 的建议,但我们制定了一份专家共识声明,建议对双侧和/或脑干有广泛缺血病变的患者不进行再灌注治疗。另一份专家共识建议,无论侧支评分如何,都应进行再灌注治疗。基于有限的证据,我们建议将直接抽吸而非支架回取作为机械血栓切除术的一线策略。作为专家共识,我们建议在经皮穿刺血管成形术和/或支架植入术失败后进行抢救性经皮穿刺血管成形术和/或支架植入术。最后,基于极低的证据确定性,我们建议在 EVT 过程中或 EVT 结束后 24 小时内,对未合并 IVT 且 EVT 过程复杂(定义为失败或即将再次闭塞,或需要额外的支架或血管成形术)的患者进行额外的抗血栓治疗。
{"title":"European Stroke Organisation and European Society for Minimally Invasive Neurological Therapy guideline on acute management of basilar artery occlusion.","authors":"Daniel Strbian, Georgios Tsivgoulis, Johanna Ospel, Silja Räty, Petra Cimflova, Georgios Georgiopoulos, Teresa Ullberg, Caroline Arquizan, Jan Gralla, Kamil Zeleňák, Salman Hussain, Jens Fiehler, Patrik Michel, Guillaume Turc, Wim Van Zwam","doi":"10.1177/23969873241257223","DOIUrl":"10.1177/23969873241257223","url":null,"abstract":"&lt;p&gt;&lt;p&gt;The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology. Although BAO accounts for only 1%-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five ESMINT) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements. First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (albeit in small numbers) in IVT trials. Non-randomised studies of IVT-only cohorts showed high proportion of favourable outcomes. Expert Consensus suggests using IVT up to 24 h unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared to BMT alone within 6 and 6-24 h from last seen well. In both time windows, we observed a different effect of treatment depending on (a) the region where the patients were treated (Europe vs. Asia), (b) on the proportion of IVT in the BMT arm, and (c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with NIHSS below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT + BMT over BMT alone (i.e. based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT + BMT over BMT alone in proximal and middle locations of BAO compared to distal location. While recommendations for patients without extensive early ischaemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischaemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certai","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":" ","pages":"835-884"},"PeriodicalIF":5.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11569583/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140946130","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"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
Incidence and predictors of intracranial hemorrhage after intravenous thrombolysis with tenecteplase. 静脉注射替奈普酶溶栓后颅内出血的发生率和预测因素。
IF 5.8 3区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-12-01 Epub Date: 2024-05-17 DOI: 10.1177/23969873241253660
Gaultier Marnat, Gaspard Gerschenfeld, Stephane Olindo, Igor Sibon, Pierre Seners, Frederic Clarençon, Didier Smadja, Nicolas Chausson, Wagih Ben Hassen, Michel Piotin, Jildaz Caroff, Sonia Alamowitch, Guillaume Turc

Background: Despite its increasing use, there are limited data on the risk of intracranial hemorrhage (ICH) after intravenous thrombolysis with tenecteplase in the setting of acute ischemic stroke. Our aim was to investigate the incidence and predictors of ICH after tenecteplase administration.

Methods: We reviewed data from the prospective ongoing multicenter TETRIS (Tenecteplase Treatment in Ischemic Stroke) registry. Patients with available day-1 imaging were included in this study. Clinical, imaging and biological variables were collected. Follow-up imaging performed 24 h after IVT was locally reviewed by senior neuroradiologists and neurologists. The incidence of parenchymal hematoma (PH) and any ICH were investigated. Potential predictors of PH and any ICH were assessed in multivariable logistic regressions. Subgroup analyses focusing on patients intended for endovascular treatment were performed.

Results: PH and any ICH occurred in 126/1321 (incidence rate: 9.5%, 95% CI 8.1-11.2) and 521/1321 (39.4%, 95% CI 36.8-42.1) patients, respectively. Symptomatic ICH was observed in 77/1321 (5.8%; 95% CI 4.7-7.2). PH occurrence was significantly associated with poorer functional outcomes (p < 0.0001) and death (p < 0.0001) after 3 months. Older age (aOR = 1.03; 95% CI 1.01-1.05), male gender (aOR = 2.07; 95% CI 1.28-3.36), a history of hypertension (aOR = 2.08; 95% CI 1.19-3.62), a higher baseline NIHSS (aOR = 1.07; 95% CI 1.03-1.10) and higher admission blood glucose level (aOR = 1.12; 95% CI 1.05-1.19) were independently associated with PH occurrence. Similar associations were observed in the subgroup of patients intended for endovascular treatment.

Conclusion: We quantified the incidence of ICH after IVT with tenecteplase in a real-life prospective registry and determined independent predictors of ICH. These findings allow to identify patients at high risk of ICH.

背景:尽管静脉注射替奈替普酶溶栓治疗急性缺血性卒中的应用越来越广泛,但有关其颅内出血(ICH)风险的数据却很有限。我们的目的是研究使用替奈普酶后 ICH 的发生率和预测因素:我们回顾了正在进行的前瞻性多中心 TETRIS(替奈替普酶治疗缺血性脑卒中)登记数据。本研究纳入了有第一天影像学资料的患者。收集了临床、影像学和生物学变量。IVT 24 小时后进行的随访成像由当地资深神经放射科医生和神经科医生进行审查。研究调查了实质血肿(PH)和任何 ICH 的发生率。通过多变量逻辑回归评估了 PH 和任何 ICH 的潜在预测因素。对打算接受血管内治疗的患者进行了分组分析:126/1321(发生率:9.5%,95% CI 8.1-11.2)和 521/1321(发生率:39.4%,95% CI 36.8-42.1)名患者分别出现了 PH 和任何 ICH。77/1321(5.8%;95% CI 4.7-7.2)例患者出现症状性 ICH。PH的发生与较差的功能预后明显相关(p p 结论:我们在真实的前瞻性登记中量化了使用替奈普酶进行 IVT 后的 ICH 发生率,并确定了 ICH 的独立预测因素。这些发现有助于识别 ICH 高危患者。
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引用次数: 0
Biomarkers to improve functional outcome prediction after ischemic stroke: Results from the SICFAIL, STRAWINSKI, and PREDICT studies. 改善缺血性脑卒中后功能预后的生物标志物:SICFAIL、STRAWINSKI 和 PREDICT 研究的结果。
IF 5.8 3区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-12-01 Epub Date: 2024-05-06 DOI: 10.1177/23969873241250272
Felipe A Montellano, Viktoria Rücker, Kathrin Ungethüm, Anna Penalba, Benjamin Hotter, Marina Giralt, Silke Wiedmann, Daniel Mackenrodt, Caroline Morbach, Stefan Frantz, Stefan Störk, William N Whiteley, Christoph Kleinschnitz, Andreas Meisel, Joan Montaner, Karl Georg Haeusler, Peter U Heuschmann

Background and aims: Acute ischemic stroke (AIS) outcome prognostication remains challenging despite available prognostic models. We investigated whether a biomarker panel improves the predictive performance of established prognostic scores.

Methods: We investigated the improvement in discrimination, calibration, and overall performance by adding five biomarkers (procalcitonin, copeptin, cortisol, mid-regional pro-atrial natriuretic peptide (MR-proANP), and N-terminal pro-B-type natriuretic peptide (NT-proBNP)) to the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) and age/NIHSS scores using data from two prospective cohort studies (SICFAIL, PREDICT) and one clinical trial (STRAWINSKI). Poor outcome was defined as mRS > 2 at 12 (SICFAIL, derivation dataset) or 3 months (PREDICT/STRAWINSKI, pooled external validation dataset).

Results: Among 412 SICFAIL participants (median age 70 years, quartiles 59-78; 63% male; median NIHSS score 3, quartiles 1-5), 29% had a poor outcome. Area under the curve of the ASTRAL and age/NIHSS were 0.76 (95% CI 0.71-0.81) and 0.77 (95% CI 0.73-0.82), respectively. Copeptin (0.79, 95% CI 0.74-0.84), NT-proBNP (0.80, 95% CI 0.76-0.84), and MR-proANP (0.79, 95% CI 0.75-0.84) significantly improved ASTRAL score's discrimination, calibration, and overall performance. Copeptin improved age/NIHSS model's discrimination, copeptin, MR-proANP, and NT-proBNP improved its calibration and overall performance. In the validation dataset (450 patients, median age 73 years, quartiles 66-81; 54% men; median NIHSS score 8, quartiles 3-14), copeptin was independently associated with various definitions of poor outcome and also mortality. Copeptin did not increase model's discrimination but it did improve calibration and overall model performance.

Discussion: Copeptin, NT-proBNP, and MR-proANP improved modest but consistently the predictive performance of established prognostic scores in patients with mild AIS. Copeptin was most consistently associated with poor outcome in patients with moderate to severe AIS, although its added prognostic value was less obvious.

背景和目的:尽管已有预后模型,但急性缺血性卒中(AIS)的预后仍然具有挑战性。我们研究了生物标记物面板是否能提高既有预后评分的预测性能:我们研究了添加五种生物标记物(降钙素原、 copeptin、皮质醇、中区域前心房钠尿肽(MR-proANP)、和 N 端前 B 型利钠肽 (NT-proBNP))以及年龄/NIHSS 评分,并利用两项前瞻性队列研究(SICFAIL、PREDICT)和一项临床试验(STRAWINSKI)的数据。不良预后定义为 12 个月时 mRS > 2(SICFAIL,衍生数据集)或 3 个月时(PREDICT/STRAWINSKI,汇总外部验证数据集):在 412 名 SICFAIL 参与者(中位年龄 70 岁,四分位数 59-78;63% 为男性;中位 NIHSS 评分 3 分,四分位数 1-5)中,29% 的患者预后不佳。ASTRAL 和年龄/NIHSS 的曲线下面积分别为 0.76(95% CI 0.71-0.81)和 0.77(95% CI 0.73-0.82)。Copeptin(0.79,95% CI 0.74-0.84)、NT-proBNP(0.80,95% CI 0.76-0.84)和 MR-proANP(0.79,95% CI 0.75-0.84)显著提高了 ASTRAL 评分的区分度、校准和整体性能。Copeptin 提高了年龄/NIHSS 模型的辨别能力,copeptin、MR-proANP 和 NT-proBNP 则提高了其校准能力和整体性能。在验证数据集(450 名患者,中位年龄 73 岁,四分位数 66-81;54% 为男性;中位 NIHSS 评分 8 分,四分位数 3-14)中,谷丙肽与各种不良预后定义以及死亡率均有独立关联。谷丙转氨酶并未提高模型的区分度,但却改善了校准和模型的整体性能:讨论:谷丙转氨酶、NT-proBNP 和 MR-proANP 对轻度 AIS 患者既有预后评分的预测性能改善不大,但持续改善。在中度至重度 AIS 患者中,谷丙转氨酶与不良预后的相关性最为一致,但其增加的预后价值并不明显。
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引用次数: 0
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European Stroke Journal
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