Introduction: Developing an effective stroke prevention strategy is crucial for elderly atrial fibrillation (AF) patients with dementia. This is due to the limited and inconsistent evidence available on this topic. In this nationwide, population-based cohort study, we aim to compare the effectiveness and safety of direct oral anticoagulants (DOACs) and warfarin in AF patients with dementia.
Patients and methods: We identified AF patients with dementia, aged 50 years or older, from Taiwan's National Health Insurance Research Database between 2010 and 2019. The primary outcome was a composite of hospitalizations due to ischemic stroke, acute myocardial infarction, intracranial hemorrhage, or major bleeding, as well as all-cause mortality. We used 1:1 propensity score matching and Cox proportional hazard models to adjust for confounding factors when comparing outcomes between warfarin and DOAC (apixaban, dabigatran, edoxaban, or rivaroxaban) users or warfarin and each individual DOAC.
Results: There were 2952 patients in the DOAC-warfarin matched cohort. The apixaban-, dabigatran-, edoxaban-, and rivaroxaban-warfarin matched cohorts had 2346, 2554, 1684, and 2938 patients, respectively. The DOAC group, when compared to warfarin, was associated with a lower risk of both the composite outcome (hazard ratio (HR), 0.81; 95% confidence interval (CI) 0.69-0.95) and ischemic stroke (HR 0.65; 95% CI 0.48-0.87). Apixaban (HR 0.79; 95% CI 0.66-0.94), dabigatran (HR 0.64; 95% CI 0.53-0.77), and rivaroxaban (HR 0.82; 95% CI 0.70-0.97) were also associated with a lower risk of the composite outcome.
Discussion and conclusion: Compared to warfarin, DOACs, whether as a group or apixaban, dabigatran, or rivaroxaban individually, were associated with a reduced risk of the composite outcome in elderly patients with concurrent AF and dementia.
导言:制定有效的中风预防策略对于老年心房颤动 (AF) 痴呆患者至关重要。这是因为这方面的证据有限且不一致。在这项基于人群的全国性队列研究中,我们旨在比较直接口服抗凝药(DOACs)和华法林对老年痴呆房颤患者的有效性和安全性:我们从 2010 年至 2019 年期间的台湾国民健康保险研究数据库中识别了 50 岁或以上的房颤痴呆患者。主要结果是缺血性中风、急性心肌梗死、颅内出血或大出血导致的住院治疗以及全因死亡率的复合结果。在比较华法林和DOAC(阿哌沙班、达比加群、依度沙班或利伐沙班)使用者之间或华法林和每种DOAC使用者之间的结果时,我们使用了1:1倾向得分匹配和Cox比例危险模型来调整混杂因素:DOAC与华法林匹配队列中有2952名患者。阿哌沙班、达比加群、依度沙班和利伐沙班-华法林匹配队列分别有 2346、2554、1684 和 2938 名患者。与华法林相比,DOAC组发生复合结局(危险比(HR)0.81;95% 置信区间(CI)0.69-0.95)和缺血性卒中(HR 0.65;95% CI 0.48-0.87)的风险较低。阿哌沙班(HR 0.79;95% CI 0.66-0.94)、达比加群(HR 0.64;95% CI 0.53-0.77)和利伐沙班(HR 0.82;95% CI 0.70-0.97)也与较低的综合结果风险相关:与华法林相比,DOACs(无论是作为一组药物还是阿哌沙班、达比加群或利伐沙班单独使用)与并发房颤和痴呆的老年患者的综合结局风险降低相关。
{"title":"Comparative effectiveness and safety of direct oral anticoagulants and warfarin in atrial fibrillation patients with dementia.","authors":"Chen-Wen Fang, Cheng-Yang Hsieh, Hsin-Yi Yang, Ching-Fang Tsai, Sheng-Feng Sung","doi":"10.1177/23969873241274598","DOIUrl":"https://doi.org/10.1177/23969873241274598","url":null,"abstract":"<p><strong>Introduction: </strong>Developing an effective stroke prevention strategy is crucial for elderly atrial fibrillation (AF) patients with dementia. This is due to the limited and inconsistent evidence available on this topic. In this nationwide, population-based cohort study, we aim to compare the effectiveness and safety of direct oral anticoagulants (DOACs) and warfarin in AF patients with dementia.</p><p><strong>Patients and methods: </strong>We identified AF patients with dementia, aged 50 years or older, from Taiwan's National Health Insurance Research Database between 2010 and 2019. The primary outcome was a composite of hospitalizations due to ischemic stroke, acute myocardial infarction, intracranial hemorrhage, or major bleeding, as well as all-cause mortality. We used 1:1 propensity score matching and Cox proportional hazard models to adjust for confounding factors when comparing outcomes between warfarin and DOAC (apixaban, dabigatran, edoxaban, or rivaroxaban) users or warfarin and each individual DOAC.</p><p><strong>Results: </strong>There were 2952 patients in the DOAC-warfarin matched cohort. The apixaban-, dabigatran-, edoxaban-, and rivaroxaban-warfarin matched cohorts had 2346, 2554, 1684, and 2938 patients, respectively. The DOAC group, when compared to warfarin, was associated with a lower risk of both the composite outcome (hazard ratio (HR), 0.81; 95% confidence interval (CI) 0.69-0.95) and ischemic stroke (HR 0.65; 95% CI 0.48-0.87). Apixaban (HR 0.79; 95% CI 0.66-0.94), dabigatran (HR 0.64; 95% CI 0.53-0.77), and rivaroxaban (HR 0.82; 95% CI 0.70-0.97) were also associated with a lower risk of the composite outcome.</p><p><strong>Discussion and conclusion: </strong>Compared to warfarin, DOACs, whether as a group or apixaban, dabigatran, or rivaroxaban individually, were associated with a reduced risk of the composite outcome in elderly patients with concurrent AF and dementia.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":5.8,"publicationDate":"2024-08-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142113254","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-30DOI: 10.1177/23969873241274512
Anna Andriana Kyselyova, Caspar Brekenfeld, Lucas Meyer, Helena Guerreiro, Gabriel Broocks, Susan Klapproth, Tobias Faizy, Christian Heitkamp, Malte Issleib, Jens Fiehler, Fabian Flottmann
Introduction: Managing blood pressure in patients with large vessel occlusion affects infarct size and clinical outcomes. We examined how restoring blood flow impacts systemic blood pressure during mechanical thrombectomy.
Patients and methods: Patients with large vessel occlusion in the anterior circulation undergoing mechanical thrombectomy between June 2016 and January 2018 were screened. We included those treated under local anesthesia or conscious sedation and analyzed standardized anesthesia protocols to assess systolic and diastolic blood pressure levels throughout the procedure. The primary outcome was the change of blood pressure, compared 5 min before versus 5 min after the last recanalization attempt. Successful reperfusion was defined as Thrombolysis in Cerebral Infarction score ⩾ 2b.
Results: Of 134 patients, 117 (87%) achieved successful angiographic reperfusion, showing a notable systolic blood pressure drop 5 min after flow restoration (10.2 ± 14.6 vs 3.24 ± 8.65 mm Hg, p = 0.009). Successful angiographic reperfusion was a significant predictor for this decrease in multivariable logistic regression: OR = 1.34 (95% CI: 1.03-1.73, p = 0.0299). Among 66 patients not given circulation-affecting meds, a significant systolic pressure reduction was also observed (155 ± 17 mm Hg to 148 ± 17 mm Hg ; p < 0.001). No diastolic pressure changes were significant.
Discussion and conclusions: Flow restoration was associated with an immediate reduction of systolic blood pressure values in patients undergoing mechanical recanalization under local anesthesia or conscious sedation. This suggests a complex interplay between endovascular stroke therapy and cardiovascular hemodynamics.
导言:大血管闭塞患者的血压管理会影响梗死面积和临床预后。我们研究了在机械血栓切除术中恢复血流如何影响全身血压:筛选了 2016 年 6 月至 2018 年 1 月间接受机械血栓切除术的前循环大血管闭塞患者。我们纳入了在局部麻醉或有意识镇静下接受治疗的患者,并分析了标准化麻醉方案,以评估整个手术过程中的收缩压和舒张压水平。主要结果是血压的变化,比较最后一次再灌注尝试前 5 分钟和尝试后 5 分钟的血压变化。脑梗塞溶栓评分⩾ 2b 定义为再灌注成功:134例患者中,117例(87%)血管再灌注成功,血流恢复后5分钟收缩压明显下降(10.2 ± 14.6 vs 3.24 ± 8.65 mm Hg,p = 0.009)。在多变量逻辑回归中,血管再灌注成功是导致血压下降的重要预测因素:OR = 1.34 (95% CI: 1.03-1.73, p = 0.0299)。在 66 名未服用影响循环药物的患者中,也观察到收缩压显著降低(从 155 ± 17 mm Hg 降至 148 ± 17 mm Hg;p 讨论和结论:在局部麻醉或有意识镇静状态下接受机械再通术的患者,血流恢复与收缩压值的立即降低有关。这表明血管内卒中治疗与心血管血流动力学之间存在复杂的相互作用。
{"title":"Flow restoration during mechanical thrombectomy for large vessel occlusion is associated with an immediate reduction of systemic blood pressure.","authors":"Anna Andriana Kyselyova, Caspar Brekenfeld, Lucas Meyer, Helena Guerreiro, Gabriel Broocks, Susan Klapproth, Tobias Faizy, Christian Heitkamp, Malte Issleib, Jens Fiehler, Fabian Flottmann","doi":"10.1177/23969873241274512","DOIUrl":"https://doi.org/10.1177/23969873241274512","url":null,"abstract":"<p><strong>Introduction: </strong>Managing blood pressure in patients with large vessel occlusion affects infarct size and clinical outcomes. We examined how restoring blood flow impacts systemic blood pressure during mechanical thrombectomy.</p><p><strong>Patients and methods: </strong>Patients with large vessel occlusion in the anterior circulation undergoing mechanical thrombectomy between June 2016 and January 2018 were screened. We included those treated under local anesthesia or conscious sedation and analyzed standardized anesthesia protocols to assess systolic and diastolic blood pressure levels throughout the procedure. The primary outcome was the change of blood pressure, compared 5 min before versus 5 min after the last recanalization attempt. Successful reperfusion was defined as Thrombolysis in Cerebral Infarction score ⩾ 2b.</p><p><strong>Results: </strong>Of 134 patients, 117 (87%) achieved successful angiographic reperfusion, showing a notable systolic blood pressure drop 5 min after flow restoration (10.2 ± 14.6 vs 3.24 ± 8.65 mm Hg, <i>p</i> = 0.009). Successful angiographic reperfusion was a significant predictor for this decrease in multivariable logistic regression: OR = 1.34 (95% CI: 1.03-1.73, <i>p</i> = 0.0299). Among 66 patients not given circulation-affecting meds, a significant systolic pressure reduction was also observed (155 ± 17 mm Hg to 148 ± 17 mm Hg ; <i>p</i> < 0.001). No diastolic pressure changes were significant.</p><p><strong>Discussion and conclusions: </strong>Flow restoration was associated with an immediate reduction of systolic blood pressure values in patients undergoing mechanical recanalization under local anesthesia or conscious sedation. This suggests a complex interplay between endovascular stroke therapy and cardiovascular hemodynamics.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":5.8,"publicationDate":"2024-08-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142113255","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-26DOI: 10.1177/23969873241272744
Jasmin Helbach, Falk Hoffmann, Nina Hecht, Christoph Heesen, Götz Thomalla, Denise Wilfling, Anne Christin Rahn
Purpose: We aimed to synthesize the information needs of people with stroke (PwS) in recurrent stroke prevention.
Methods: In this scoping review we searched Medline (via PubMed), CINAHL, and PsycINFO from inception to June 5, 2023, to identify all studies describing the information needs of people 18 years and older who have suffered a stroke or transient ischemic attack within the past 5 years. We included qualitative and quantitative studies from developed countries published in German or English. Data analysis was performed following Arksey and O'Malley's methodological framework for scoping reviews.
Findings: We screened 5822 records for eligibility and included 36 articles published between 1993 and 2023. None of the included studies used a comprehensive framework or defined information needs. Based on statements from PwS and their caregivers, PwS needed information on treatment, etiology, effects of stroke, prognosis, rehabilitation, discharge, life changes, care role, support options, information sources, and hospital procedures. The most frequently expressed needs were information on the treatment (77.8%) and stroke etiology (63.9%). The primary information source was healthcare professionals (85.7%), followed by written information (71.4%), family and friends (42.6%), and the internet (35.7%), with information provided directly by healthcare professionals being preferred. The timing of information transfer is often described as too early.
Conclusion: PwS are primarily interested in clinical information about stroke, for example, treatment and etiology, and less often in information about daily life, for example, rehabilitation, the role of care, or lifestyle changes. PwS prefer to receive information directly from healthcare professionals. Developing a shared understanding of PwS's information needs is crucial to implement suitable strategies and programs for dealing with these needs in clinical practice.
{"title":"Information needs of people who have suffered a stroke or TIA and their preferred approaches of receiving health information: A scoping review.","authors":"Jasmin Helbach, Falk Hoffmann, Nina Hecht, Christoph Heesen, Götz Thomalla, Denise Wilfling, Anne Christin Rahn","doi":"10.1177/23969873241272744","DOIUrl":"https://doi.org/10.1177/23969873241272744","url":null,"abstract":"<p><strong>Purpose: </strong>We aimed to synthesize the information needs of people with stroke (PwS) in recurrent stroke prevention.</p><p><strong>Methods: </strong>In this scoping review we searched Medline (via PubMed), CINAHL, and PsycINFO from inception to June 5, 2023, to identify all studies describing the information needs of people 18 years and older who have suffered a stroke or transient ischemic attack within the past 5 years. We included qualitative and quantitative studies from developed countries published in German or English. Data analysis was performed following Arksey and O'Malley's methodological framework for scoping reviews.</p><p><strong>Findings: </strong>We screened 5822 records for eligibility and included 36 articles published between 1993 and 2023. None of the included studies used a comprehensive framework or defined information needs. Based on statements from PwS and their caregivers, PwS needed information on treatment, etiology, effects of stroke, prognosis, rehabilitation, discharge, life changes, care role, support options, information sources, and hospital procedures. The most frequently expressed needs were information on the treatment (77.8%) and stroke etiology (63.9%). The primary information source was healthcare professionals (85.7%), followed by written information (71.4%), family and friends (42.6%), and the internet (35.7%), with information provided directly by healthcare professionals being preferred. The timing of information transfer is often described as too early.</p><p><strong>Conclusion: </strong>PwS are primarily interested in clinical information about stroke, for example, treatment and etiology, and less often in information about daily life, for example, rehabilitation, the role of care, or lifestyle changes. PwS prefer to receive information directly from healthcare professionals. Developing a shared understanding of PwS's information needs is crucial to implement suitable strategies and programs for dealing with these needs in clinical practice.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":5.8,"publicationDate":"2024-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142074201","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-26DOI: 10.1177/23969873241272507
Damjan Mirkov, Ekkehart Jenetzky, Andrea S Thieme, Adeeb Qabalan, Christoph Gumbinger, Wolfgang Wick, Peter A Ringleb, Timolaos Rizos
Introduction: Patients with acute ischemic stroke (AIS) and large-vessel occlusion are frequently transferred by emergency physicians (EPs) from primary to comprehensive stroke centers (CSC) for thrombectomy, particular when thrombolysed. Data on complications during such transfers are highly limited.
Patients and methods: Consecutive AIS patients transferred between 01/2015 and 10/2021 to our CSC were included. Associations of major (MACO) and minor (MICO) complications with clinical and imaging data were assessed.
Results: In total, 985 patients were included in the analysis (58.5% thrombolysed). MACO developed in 1.6%, MICO in 14.6%. Compared to patients without complications (NOCO), patients with MACO did not differ in terms of demographics, cerebrovascular risk factors, or site of vessel occlusion. They had more severe strokes (p = 0.026), neurological worsening was more severe (p = 0.008), and transport duration was longer (p = 0.050) but geographical distances did not differ. Thrombolysed patients had any complication more often than patients without thrombolysis (20.3% vs 10.5%; p< 0.001); however, this finding was driven by patients with MICO (p< 0.001) only (MACO: p = 0.804). No associations were observed between stroke severity and complications in either thrombolysed or nonthrombolysed patients. Neurological deterioration during transfer was observed in 21.2%, but multivariate analysis revealed no association with thrombolysis (OR 0.962; 95%CI 0.670-1.380, p = 0.832). Asymptomatic intracerebral hemorrhage was present in 1.1%, symptomatic in 0.1%.
Discussion and conclusion: In this large cohort, no patient-specific factor increasing the risk of complications during interhospital transfer was identified. Specifically, our results do not indicate that thrombolysis increases MACO. Hence, interhospital transfer without EPs appears reasonable in most patients.
{"title":"Medical complications during interhospital transfer for thrombectomy in patients with acute ischemic stroke.","authors":"Damjan Mirkov, Ekkehart Jenetzky, Andrea S Thieme, Adeeb Qabalan, Christoph Gumbinger, Wolfgang Wick, Peter A Ringleb, Timolaos Rizos","doi":"10.1177/23969873241272507","DOIUrl":"https://doi.org/10.1177/23969873241272507","url":null,"abstract":"<p><strong>Introduction: </strong>Patients with acute ischemic stroke (AIS) and large-vessel occlusion are frequently transferred by emergency physicians (EPs) from primary to comprehensive stroke centers (CSC) for thrombectomy, particular when thrombolysed. Data on complications during such transfers are highly limited.</p><p><strong>Patients and methods: </strong>Consecutive AIS patients transferred between 01/2015 and 10/2021 to our CSC were included. Associations of major (MACO) and minor (MICO) complications with clinical and imaging data were assessed.</p><p><strong>Results: </strong>In total, 985 patients were included in the analysis (58.5% thrombolysed). MACO developed in 1.6%, MICO in 14.6%. Compared to patients without complications (NOCO), patients with MACO did not differ in terms of demographics, cerebrovascular risk factors, or site of vessel occlusion. They had more severe strokes (<i>p</i> = 0.026), neurological worsening was more severe (<i>p</i> = 0.008), and transport duration was longer (<i>p</i> = 0.050) but geographical distances did not differ. Thrombolysed patients had any complication more often than patients without thrombolysis (20.3% vs 10.5%; <i>p</i> <i><</i> 0.001); however, this finding was driven by patients with MICO (<i>p</i> <i><</i> 0.001) only (MACO: <i>p</i> = 0.804). No associations were observed between stroke severity and complications in either thrombolysed or nonthrombolysed patients. Neurological deterioration during transfer was observed in 21.2%, but multivariate analysis revealed no association with thrombolysis (OR 0.962; 95%CI 0.670-1.380, <i>p</i> = 0.832). Asymptomatic intracerebral hemorrhage was present in 1.1%, symptomatic in 0.1%.</p><p><strong>Discussion and conclusion: </strong>In this large cohort, no patient-specific factor increasing the risk of complications during interhospital transfer was identified. Specifically, our results do not indicate that thrombolysis increases MACO. Hence, interhospital transfer without EPs appears reasonable in most patients.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":5.8,"publicationDate":"2024-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142056888","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-22DOI: 10.1177/23969873241272542
Victor Schulze-Zachau, Nikki Rommers, Nikolaos Ntoulias, Alex Brehm, Nadja Krug, Ioannis Tsogkas, Matthias Mutke, Thilo Rusche, Amedeo Cervo, Claudia Rollo, Markus Möhlenbruch, Jessica Jesser, Kornelia Kreiser, Katharina Althaus, Manuel Requena, Marc Rodrigo-Gisbert, Tomas Dobrocky, Bettina L Serrallach, Christian H Nolte, Christoph Riegler, Jawed Nawabi, Errikos Maslias, Patrik Michel, Guillaume Saliou, Nathan Manning, Alexander McQuinn, Alon Taylor, Christoph J Maurer, Ansgar Berlis, Daniel Po Kaiser, Ani Cuberi, Manuel Moreu, Alfonso López-Frías, Carlos Pérez-García, Riitta Rautio, Ylikotila Pauli, Nicola Limbucci, Leonardo Renieri, Isabel Fragata, Tania Rodriguez-Ares, Jan S Kirschke, Julian Schwarting, Sami Al Kasab, Alejandro M Spiotta, Ahmad Abu Qdais, Adam A Dmytriw, Robert W Regenhardt, Aman B Patel, Vitor Mendes Pereira, Nicole M Cancelliere, Carsten Schmeel, Franziska Dorn, Malte Sauer, Grzegorz M Karwacki, Jane Khalife, Ajith J Thomas, Hamza A Shaikh, Christian Commodaro, Marco Pileggi, Roland Schwab, Flavio Bellante, Anne Dusart, Jeremy Hofmeister, Paolo Machi, Edgar A Samaniego, Diego J Ojeda, Robert M Starke, Ahmed Abdelsalam, Frans van den Bergh, Sylvie De Raedt, Maxim Bester, Fabian Flottmann, Daniel Weiss, Marius Kaschner, Peter T Kan, Gautam Edhayan, Michael R Levitt, Spencer L Raub, Mira Katan, Urs Fischer, Marios-Nikos Psychogios
Introduction: Thrombectomy complications remain poorly explored. This study aims to characterize periprocedural intracranial vessel perforation including the effect of thrombolysis on patient outcomes.
Patients and methods: In this multicenter retrospective cohort study, consecutive patients with vessel perforation during thrombectomy between January 2015 and April 2023 were included. Vessel perforation was defined as active extravasation on digital subtraction angiography. The primary outcome was modified Rankin Scale (mRS) at 90 days. Factors associated with the primary outcome were assessed using proportional odds models.
Results: 459 patients with vessel perforation were included (mean age 72.5 ± 13.6 years, 59% female, 41% received thrombolysis). Mortality at 90 days was 51.9% and 16.3% of patients reached mRS 0-2 at 90 days. Thrombolysis was not associated with worse outcome at 90 days. Perforation of a large vessel (LV) as opposed to medium/distal vessel perforation was independently associated with worse outcome at 90 days (aOR 1.709, p = 0.04) and LV perforation was associated with poorer survival probability (HR 1.389, p = 0.021). Patients with active bleeding >20 min had worse survival probability, too (HR 1.797, p = 0.009). Thrombolysis was not associated with longer bleeding duration. Bleeding cessation was achieved faster by permanent vessel occlusion compared to temporary measures (median difference: 4 min, p < 0.001).
Discussion and conclusion: Vessel perforation during thrombectomy is a severe and frequently fatal complication. This study does not suggest that thrombolysis significantly attributes to worse prognosis. Prompt cessation of active bleeding within 20 min is critical, emphasizing the need for interventionalists to be trained in complication management.
{"title":"\"Insights into vessel perforations during thrombectomy: Characteristics of a severe complication and the effect of thrombolysis\".","authors":"Victor Schulze-Zachau, Nikki Rommers, Nikolaos Ntoulias, Alex Brehm, Nadja Krug, Ioannis Tsogkas, Matthias Mutke, Thilo Rusche, Amedeo Cervo, Claudia Rollo, Markus Möhlenbruch, Jessica Jesser, Kornelia Kreiser, Katharina Althaus, Manuel Requena, Marc Rodrigo-Gisbert, Tomas Dobrocky, Bettina L Serrallach, Christian H Nolte, Christoph Riegler, Jawed Nawabi, Errikos Maslias, Patrik Michel, Guillaume Saliou, Nathan Manning, Alexander McQuinn, Alon Taylor, Christoph J Maurer, Ansgar Berlis, Daniel Po Kaiser, Ani Cuberi, Manuel Moreu, Alfonso López-Frías, Carlos Pérez-García, Riitta Rautio, Ylikotila Pauli, Nicola Limbucci, Leonardo Renieri, Isabel Fragata, Tania Rodriguez-Ares, Jan S Kirschke, Julian Schwarting, Sami Al Kasab, Alejandro M Spiotta, Ahmad Abu Qdais, Adam A Dmytriw, Robert W Regenhardt, Aman B Patel, Vitor Mendes Pereira, Nicole M Cancelliere, Carsten Schmeel, Franziska Dorn, Malte Sauer, Grzegorz M Karwacki, Jane Khalife, Ajith J Thomas, Hamza A Shaikh, Christian Commodaro, Marco Pileggi, Roland Schwab, Flavio Bellante, Anne Dusart, Jeremy Hofmeister, Paolo Machi, Edgar A Samaniego, Diego J Ojeda, Robert M Starke, Ahmed Abdelsalam, Frans van den Bergh, Sylvie De Raedt, Maxim Bester, Fabian Flottmann, Daniel Weiss, Marius Kaschner, Peter T Kan, Gautam Edhayan, Michael R Levitt, Spencer L Raub, Mira Katan, Urs Fischer, Marios-Nikos Psychogios","doi":"10.1177/23969873241272542","DOIUrl":"https://doi.org/10.1177/23969873241272542","url":null,"abstract":"<p><strong>Introduction: </strong>Thrombectomy complications remain poorly explored. This study aims to characterize periprocedural intracranial vessel perforation including the effect of thrombolysis on patient outcomes.</p><p><strong>Patients and methods: </strong>In this multicenter retrospective cohort study, consecutive patients with vessel perforation during thrombectomy between January 2015 and April 2023 were included. Vessel perforation was defined as active extravasation on digital subtraction angiography. The primary outcome was modified Rankin Scale (mRS) at 90 days. Factors associated with the primary outcome were assessed using proportional odds models.</p><p><strong>Results: </strong>459 patients with vessel perforation were included (mean age 72.5 ± 13.6 years, 59% female, 41% received thrombolysis). Mortality at 90 days was 51.9% and 16.3% of patients reached mRS 0-2 at 90 days. Thrombolysis was not associated with worse outcome at 90 days. Perforation of a large vessel (LV) as opposed to medium/distal vessel perforation was independently associated with worse outcome at 90 days (aOR 1.709, <i>p</i> = 0.04) and LV perforation was associated with poorer survival probability (HR 1.389, <i>p</i> = 0.021). Patients with active bleeding >20 min had worse survival probability, too (HR 1.797, <i>p</i> = 0.009). Thrombolysis was not associated with longer bleeding duration. Bleeding cessation was achieved faster by permanent vessel occlusion compared to temporary measures (median difference: 4 min, <i>p</i> < 0.001).</p><p><strong>Discussion and conclusion: </strong>Vessel perforation during thrombectomy is a severe and frequently fatal complication. This study does not suggest that thrombolysis significantly attributes to worse prognosis. Prompt cessation of active bleeding within 20 min is critical, emphasizing the need for interventionalists to be trained in complication management.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":5.8,"publicationDate":"2024-08-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142019139","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-21DOI: 10.1177/23969873241272631
Isuru Induruwa, Shiv Bhakta, Rahul Herlekar, Akangsha Sur Roy, Saur Hajiev, Elizabeth A Warburton, Kayvan Khadjooi, John J McCabe
Introduction: Atrial fibrillation (AF) detected after stroke (AFDAS) may represent a distinct clinical entity to that of known AF (KAF). However, there is limited long-term outcome data available for patients with AFDAS. More information regarding prognosis in AFDAS is required to inform future trial design in these patients.
Patients and methods: We used data (2015-2019) from a national prospective stroke registry of consecutive patients with acute ischaemic stroke and AF. AFDAS was defined as a new diagnosis of AF after stroke detected on electrocardiograph or cardiac monitoring. The co-primary endpoints were: (1) all-cause mortality; (2) recurrent major adverse cardiovascular events (MACE) at 3 years. Secondary endpoints were: (1) recurrent stroke; (2) functional outcome at discharge; (3) presence of co-existing stroke mechanisms.
Results: 583 patients were included. After a median follow-up of 2.65 years (cumulative 1064 person-years) 309 patients died and 23 had recurrent MACE. Compared with AFDAS, KAF was associated with a higher risk of all-cause mortality (adjusted Hazard Ratio (aHR) 1.56, 95% CI 1.12-2.18), a higher prevalence of co-existing stroke mechanisms (adjusted odds ratio (aOR) 2.28, 95% CI 1.14-4.59), but not poor functional outcome (aOR 1.61, 95% CI 0.98-2.64). A trend towards a higher risk of MACE was observed in patients with KAF, but this was limited by statistical power (aHR 2.90, 95% CI 0.67-12.51). All 14 recurrent strokes occurred in the KAF group (Log-rank p = 0.03).
Discussion and conclusion: These data provide further evidence that AFDAS differs to KAF with respect to risk of recurrent stroke, MACE, and all-cause mortality.
{"title":"Recurrent vascular events and mortality outcomes in patients with known atrial fibrillation, compared to atrial fibrillation detected early after stroke.","authors":"Isuru Induruwa, Shiv Bhakta, Rahul Herlekar, Akangsha Sur Roy, Saur Hajiev, Elizabeth A Warburton, Kayvan Khadjooi, John J McCabe","doi":"10.1177/23969873241272631","DOIUrl":"https://doi.org/10.1177/23969873241272631","url":null,"abstract":"<p><strong>Introduction: </strong>Atrial fibrillation (AF) detected after stroke (AFDAS) may represent a distinct clinical entity to that of known AF (KAF). However, there is limited long-term outcome data available for patients with AFDAS. More information regarding prognosis in AFDAS is required to inform future trial design in these patients.</p><p><strong>Patients and methods: </strong>We used data (2015-2019) from a national prospective stroke registry of consecutive patients with acute ischaemic stroke and AF. AFDAS was defined as a new diagnosis of AF after stroke detected on electrocardiograph or cardiac monitoring. The co-primary endpoints were: (1) all-cause mortality; (2) recurrent major adverse cardiovascular events (MACE) at 3 years. Secondary endpoints were: (1) recurrent stroke; (2) functional outcome at discharge; (3) presence of co-existing stroke mechanisms.</p><p><strong>Results: </strong>583 patients were included. After a median follow-up of 2.65 years (cumulative 1064 person-years) 309 patients died and 23 had recurrent MACE. Compared with AFDAS, KAF was associated with a higher risk of all-cause mortality (adjusted Hazard Ratio (aHR) 1.56, 95% CI 1.12-2.18), a higher prevalence of co-existing stroke mechanisms (adjusted odds ratio (aOR) 2.28, 95% CI 1.14-4.59), but not poor functional outcome (aOR 1.61, 95% CI 0.98-2.64). A trend towards a higher risk of MACE was observed in patients with KAF, but this was limited by statistical power (aHR 2.90, 95% CI 0.67-12.51). All 14 recurrent strokes occurred in the KAF group (Log-rank <i>p</i> = 0.03).</p><p><strong>Discussion and conclusion: </strong>These data provide further evidence that AFDAS differs to KAF with respect to risk of recurrent stroke, MACE, and all-cause mortality.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":5.8,"publicationDate":"2024-08-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142019140","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-20DOI: 10.1177/23969873241272517
Ghil Schwarz, Angelo Cascio Rizzo, Marius Matusevicius, Tiago Moreira, Aleksandras Vilionskis, Andrea Naldi, Nicolas Martinez-Majander, Guido Bigliardi, Danilo Toni, Christine Roffe, Elio Clemente Agostoni, Niaz Ahmed
Introduction: Endovascular treatment (EVT) improves outcomes for basilar artery occlusion (BAO) with moderate-to-severe symptoms. However, the best treatment for mild symptoms (NIHSS score 0-10 and 0-5) remains unclear. This study compared EVT ± IVT to IVT alone in BAO patients with mild symptoms.
Patients and methods: From the SITS-International Stroke Treatment Register, we included BAO patients with available baseline NIHSS score, treated by EVT, IVT, or both within 6 h of symptom onset from 2013 to 2021. Using the Doubly Robust approach (propensity score matching plus multivariable logistic regression), we analyzed efficacy (3-month mRS) and safety (SICH and 3-month death) outcomes for EVT ± IVT versus IVT alone in BAO patients with NIHSS scores 0-10 and 0-5.
Results: 1426 patients were included. For NIHSS scores 0-10 (180 matched, 1:1 ratio), outcomes were similar between EVT ± IVT and IVT alone groups. For NIHSS scores 0-5 (89 matched, 1:1 ratio), EVT ± IVT was associated with worse outcomes compared to IVT alone (mRS 0-2, aOR 0.20 [95% CI 0.06-0.61]; p = 0.005; mRS 0-3, aOR 0.27 [95% CI 0.08-0.89]; p = 0.031), but safety outcomes were similar.
Discussion: In early-treated BAO patients with mild symptoms, defined as NIHSS 0-10, there were no significant differences in outcomes between EVT ± IVT and IVT alone. However, for very mild symptoms, defined as NIHSS 0-5, IVT alone was associated with better outcomes compared to EVT ± IVT.Conclusion: Randomized trials are crucial to determine the optimal reperfusion therapy for BAO patients with mild symptoms.
{"title":"Reperfusion treatment in basilar artery occlusion presenting with mild symptoms.","authors":"Ghil Schwarz, Angelo Cascio Rizzo, Marius Matusevicius, Tiago Moreira, Aleksandras Vilionskis, Andrea Naldi, Nicolas Martinez-Majander, Guido Bigliardi, Danilo Toni, Christine Roffe, Elio Clemente Agostoni, Niaz Ahmed","doi":"10.1177/23969873241272517","DOIUrl":"https://doi.org/10.1177/23969873241272517","url":null,"abstract":"<p><strong>Introduction: </strong>Endovascular treatment (EVT) improves outcomes for basilar artery occlusion (BAO) with moderate-to-severe symptoms. However, the best treatment for mild symptoms (NIHSS score 0-10 and 0-5) remains unclear. This study compared EVT ± IVT to IVT alone in BAO patients with mild symptoms.</p><p><strong>Patients and methods: </strong>From the SITS-International Stroke Treatment Register, we included BAO patients with available baseline NIHSS score, treated by EVT, IVT, or both within 6 h of symptom onset from 2013 to 2021. Using the Doubly Robust approach (propensity score matching plus multivariable logistic regression), we analyzed efficacy (3-month mRS) and safety (SICH and 3-month death) outcomes for EVT ± IVT versus IVT alone in BAO patients with NIHSS scores 0-10 and 0-5.</p><p><strong>Results: </strong>1426 patients were included. For NIHSS scores 0-10 (180 matched, 1:1 ratio), outcomes were similar between EVT ± IVT and IVT alone groups. For NIHSS scores 0-5 (89 matched, 1:1 ratio), EVT ± IVT was associated with worse outcomes compared to IVT alone (mRS 0-2, aOR 0.20 [95% CI 0.06-0.61]; <i>p</i> = 0.005; mRS 0-3, aOR 0.27 [95% CI 0.08-0.89]; <i>p</i> = 0.031), but safety outcomes were similar.</p><p><strong>Discussion: </strong>In early-treated BAO patients with mild symptoms, defined as NIHSS 0-10, there were no significant differences in outcomes between EVT ± IVT and IVT alone. However, for very mild symptoms, defined as NIHSS 0-5, IVT alone was associated with better outcomes compared to EVT ± IVT.<b>Conclusion:</b> Randomized trials are crucial to determine the optimal reperfusion therapy for BAO patients with mild symptoms.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":5.8,"publicationDate":"2024-08-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142005522","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-19DOI: 10.1177/23969873241272530
Bonaventure Ip, Terry Yip, Trista Hung, Tsz-Fai Yam, Carly Yeung, Ho Ko, Grace Wong, Xinyi Leng, Vincent Mok, Yannie Soo, David Seiffge, Ashkan Shoamanesh, Thomas Leung
Introduction: The risk of ischemic stroke and intracerebral hemorrhage (ICH) with intensive lipid control by statins among patients with atrial fibrillation (AF) who require direct oral anticoagulants (DOAC) is unclear. We aimed to determine the risks of ischemic stroke and ICH in AF patients treated with DOAC and statins.
Patients and methods: In a population-based retrospective cohort study, we identified AF patients concurrently on DOAC and statins from 2015 to 2021 in Hong Kong. Primary outcome was ischemic stroke. Secondary outcomes were ICH and death. We correlated study outcomes with low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) as time-varying, continuous variables with restricted cubic spline. In secondary analyses, the risks of study outcomes with statin intensity (low, moderate, high) were determined by multivariable time-dependent marginal structural Cox models.
Results: We identified 32,752 AF patients co-prescribed with DOAC and statins. Lower LDL-C (p < 0.001) and higher HDL-C (p < 0.001) levels were associated with lower risk of ischemic stroke but not significantly associated with ICH. LDL-C of <1.8 mmol/L (70 mg/dL) was not associated with mortality (19.6% vs 18.4%, difference 1.2% [95% CI -0.35 to 2.13]). High-intensity statin was associated with a lower risk of ischemic stroke compared with low-intensity statin (weighted Cox-specific hazard ratio [95% CI]: 0.82 [0.67-0.99], p = 0.040) independent of LDL-C levels. Similar associations were found in 11,444 AF patients with a history of ischemic stroke.
Discussion and conclusion: Intensive lipid control by high-intensity statins was associated with a lower risk of ischemic stroke in AF patients who required DOACs and did not appear to increase the risk of ICH.
导言:在需要直接口服抗凝药(DOAC)的房颤(AF)患者中,使用他汀类药物强化血脂控制缺血性卒中和脑内出血(ICH)的风险尚不明确。我们旨在确定接受 DOAC 和他汀类药物治疗的房颤患者发生缺血性卒中和 ICH 的风险:在一项基于人群的回顾性队列研究中,我们确定了 2015 年至 2021 年期间在香港同时服用 DOAC 和他汀类药物的房颤患者。主要结果为缺血性卒中。次要结局为 ICH 和死亡。我们将研究结果与作为时变连续变量的低密度脂蛋白胆固醇(LDL-C)和高密度脂蛋白胆固醇(HDL-C)相关联,并使用限制性立方样条。在二次分析中,研究结果与他汀类药物强度(低、中、高)的风险是通过多变量时间依赖性边际结构 Cox 模型确定的:结果:我们确定了 32,752 名同时服用 DOAC 和他汀类药物的房颤患者。低密度脂蛋白胆固醇较低(p p = 0.040)与低密度脂蛋白胆固醇水平无关。在 11,444 名有缺血性中风病史的房颤患者中也发现了类似的关联:通过高强度他汀类药物强化血脂控制与需要 DOACs 的房颤患者缺血性卒中风险降低有关,似乎不会增加 ICH 风险。
{"title":"Lipid control and stroke risk in atrial fibrillation patients treated with direct oral anticoagulants and statins.","authors":"Bonaventure Ip, Terry Yip, Trista Hung, Tsz-Fai Yam, Carly Yeung, Ho Ko, Grace Wong, Xinyi Leng, Vincent Mok, Yannie Soo, David Seiffge, Ashkan Shoamanesh, Thomas Leung","doi":"10.1177/23969873241272530","DOIUrl":"https://doi.org/10.1177/23969873241272530","url":null,"abstract":"<p><strong>Introduction: </strong>The risk of ischemic stroke and intracerebral hemorrhage (ICH) with intensive lipid control by statins among patients with atrial fibrillation (AF) who require direct oral anticoagulants (DOAC) is unclear. We aimed to determine the risks of ischemic stroke and ICH in AF patients treated with DOAC and statins.</p><p><strong>Patients and methods: </strong>In a population-based retrospective cohort study, we identified AF patients concurrently on DOAC and statins from 2015 to 2021 in Hong Kong. Primary outcome was ischemic stroke. Secondary outcomes were ICH and death. We correlated study outcomes with low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) as time-varying, continuous variables with restricted cubic spline. In secondary analyses, the risks of study outcomes with statin intensity (low, moderate, high) were determined by multivariable time-dependent marginal structural Cox models.</p><p><strong>Results: </strong>We identified 32,752 AF patients co-prescribed with DOAC and statins. Lower LDL-C (<i>p</i> < 0.001) and higher HDL-C (<i>p</i> < 0.001) levels were associated with lower risk of ischemic stroke but not significantly associated with ICH. LDL-C of <1.8 mmol/L (70 mg/dL) was not associated with mortality (19.6% vs 18.4%, difference 1.2% [95% CI -0.35 to 2.13]). High-intensity statin was associated with a lower risk of ischemic stroke compared with low-intensity statin (weighted Cox-specific hazard ratio [95% CI]: 0.82 [0.67-0.99], <i>p</i> = 0.040) independent of LDL-C levels. Similar associations were found in 11,444 AF patients with a history of ischemic stroke.</p><p><strong>Discussion and conclusion: </strong>Intensive lipid control by high-intensity statins was associated with a lower risk of ischemic stroke in AF patients who required DOACs and did not appear to increase the risk of ICH.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":5.8,"publicationDate":"2024-08-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142001006","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-16DOI: 10.1177/23969873241271745
Umberto Pensato, Koji Tanaka, MacKenzie Horn, Ericka Teleg, Abdulaziz Sulaiman Al Sultan, Linda Kasickova, Tomoyuki Ohara, Piyush Ojha, Sina Marzoughi, Ankur Banerjee, Girish Kulkarni, Dar Dowlatshahi, Mayank Goyal, Bijoy K Menon, Andrew M Demchuk
Background: Existing radiological markers of hematoma expansion (HE) show modest predictive accuracy. We aim to investigate a novel radiological marker that co-localizes findings from non-contrast CT (NCCT) and CT angiography (CTA) to predict HE.
Methods: Consecutive acute intracerebral hemorrhage patients admitted at Foothills Medical Centre in Calgary, Canada, were included. The Black-&-White sign was defined as any visually identified spot sign on CTA co-localized with a hypodensity sign on the corresponding NCCT. The primary outcome was hematoma expansion (⩾6 mL or ⩾33%). Secondary outcomes included absolute (<3, 3-6, 6-12, ⩾12 mL) and relative (0%, <25%, 25%-50%, 50%-75%, or >75%) hematoma growth scales.
Results: Two-hundred patients were included, with 50 (25%) experiencing HE. Forty-four (22%) showed the spot sign, 69 (34.5%) the hypodensity sign, and 14 (7%) co-localized both as the Black-&-White sign. Those with the Black-&-White sign had higher proportions of HE (100% vs 19.4%, p < 0.001), greater absolute hematoma growth (23.37 mL (IQR = 15.41-30.27) vs 0 mL (IQR = 0-2.39), p < 0.001) and relative hematoma growth (120% (IQR = 49-192) vs 0% (0-15%), p < 0.001). The Black-&-White sign had a specificity of 100% (95%CI = 97.6%-100%), a positive predictive value of 100% (95%CI = 76.8%-100%), and an overall accuracy of 82% (95%CI = 76%-87.1%). Among the 14 patients with the Black-&-White sign, 13 showed an absolute hematoma growth ⩾12 mL, and 10 experienced a HE exceeding 75% of the initial volume. The inter-rater agreement was excellent (kappa coefficient = 0.84).
Conclusion: The Black-&-White sign is a robust predictor of hematoma expansion occurrence and severity, yet further validation is needed to confirm these compelling findings.
背景:血肿扩大(HE)的现有放射学标志物显示出适度的预测准确性。我们旨在研究一种新型放射学标志物,它能将非对比 CT(NCCT)和 CT 血管造影(CTA)的结果共同定位,从而预测 HE:方法:纳入加拿大卡尔加里 Foothills 医疗中心收治的连续急性脑内出血患者。黑白征的定义是 CTA 上任何可视化识别的斑点征与相应 NCCT 上的低密度征共同定位。主要结果是血肿扩大(⩾6 mL 或 ⩾33%)。次要结果包括血肿增长绝对值(75%):共纳入 200 例患者,其中 50 例(25%)出现高血压。44人(22%)出现斑点征,69人(34.5%)出现低密度征,14人(7%)同时出现黑白征。黑白征的患者中 HE 的比例较高(100% 对 19.4%,p p p 结论):黑白征是血肿扩大发生和严重程度的可靠预测指标,但还需要进一步验证才能证实这些令人信服的发现。
{"title":"Co-localization of NCCT hypodensity and CTA spot sign predicts substantial intracerebral hematoma expansion: The Black-&-White sign.","authors":"Umberto Pensato, Koji Tanaka, MacKenzie Horn, Ericka Teleg, Abdulaziz Sulaiman Al Sultan, Linda Kasickova, Tomoyuki Ohara, Piyush Ojha, Sina Marzoughi, Ankur Banerjee, Girish Kulkarni, Dar Dowlatshahi, Mayank Goyal, Bijoy K Menon, Andrew M Demchuk","doi":"10.1177/23969873241271745","DOIUrl":"https://doi.org/10.1177/23969873241271745","url":null,"abstract":"<p><strong>Background: </strong>Existing radiological markers of hematoma expansion (HE) show modest predictive accuracy. We aim to investigate a novel radiological marker that co-localizes findings from non-contrast CT (NCCT) and CT angiography (CTA) to predict HE.</p><p><strong>Methods: </strong>Consecutive acute intracerebral hemorrhage patients admitted at Foothills Medical Centre in Calgary, Canada, were included. The Black-&-White sign was defined as any visually identified spot sign on CTA co-localized with a hypodensity sign on the corresponding NCCT. The primary outcome was hematoma expansion (⩾6 mL or ⩾33%). Secondary outcomes included absolute (<3, 3-6, 6-12, ⩾12 mL) and relative (0%, <25%, 25%-50%, 50%-75%, or >75%) hematoma growth scales.</p><p><strong>Results: </strong>Two-hundred patients were included, with 50 (25%) experiencing HE. Forty-four (22%) showed the spot sign, 69 (34.5%) the hypodensity sign, and 14 (7%) co-localized both as the Black-&-White sign. Those with the Black-&-White sign had higher proportions of HE (100% vs 19.4%, <i>p</i> < 0.001), greater absolute hematoma growth (23.37 mL (IQR = 15.41-30.27) vs 0 mL (IQR = 0-2.39), <i>p</i> < 0.001) and relative hematoma growth (120% (IQR = 49-192) vs 0% (0-15%), <i>p</i> < 0.001). The Black-&-White sign had a specificity of 100% (95%CI = 97.6%-100%), a positive predictive value of 100% (95%CI = 76.8%-100%), and an overall accuracy of 82% (95%CI = 76%-87.1%). Among the 14 patients with the Black-&-White sign, 13 showed an absolute hematoma growth ⩾12 mL, and 10 experienced a HE exceeding 75% of the initial volume. The inter-rater agreement was excellent (kappa coefficient = 0.84).</p><p><strong>Conclusion: </strong>The Black-&-White sign is a robust predictor of hematoma expansion occurrence and severity, yet further validation is needed to confirm these compelling findings.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":5.8,"publicationDate":"2024-08-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141989191","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-16DOI: 10.1177/23969873241271642
Maximilian Schell, Christina Mayer, Marcel Seungsu Woo, Hannes Leischner, Marlene Fischer, Jörn Grensemann, Stefan Kluge, Patrick Czorlich, Christian Gerloff, Jens Fiehler, Götz Thomalla, Fabian Flottmann, Nils Schweingruber
Introduction: Endovascular thrombectomy stands as a pivotal component in the standard care for patients experiencing acute ischemic stroke with large vessel occlusion. Subsequent care for patients often extends to a neurological intensive care unit. While fluid management is integral to intensive care, the association between early fluid balance and neurological and functional outcomes post-thrombectomy has not yet been thoroughly investigated.
Methods: In a retrospective analysis of an observational, single-center study spanning from 2015 to 2021 at the University Medical Center Hamburg-Eppendorf, Germany, we enrolled stroke patients who underwent thrombectomy and received subsequent treatment in the ICU. Unfavorable functional and neurological outcome was defined as a mRS > 2 on day 90 after admission (mRS d90) or NIHSS > 5 at discharge, respectively. A multivariate regression model, adjusting for confounders, utilized the average fluid balance in the first 5 days to predict outcomes. Patients were dichotomized by their average fluid balance (>1 L vs <1 L) within the first 5 days, and a multivariate mRS d90 shift analysis was conducted after adjusting for covariates.
Results: Between 2015 and 2021, 1252 patients underwent thrombectomy, and 553 patients met the inclusion criteria (299 women [54%]). Unfavorable functional outcome was significantly associated with a higher daily average fluid balance in the first 5 days in the ICU (mRS d90 ⩽ 2: 0.3 ± 0.5 L, mRS d90 > 2: 0.7 ± 0.7 L, p = 0.02). The same association was observed for the NIHSS at discharge (NIHSS ⩽ 5: 0.3 ± 0.5 L; NIHSS > 5: 0.6 ± 0.6 L; p = 0.03). The mRS d90 shift analysis revealed significance for patients with an average fluid balance <1 L for better functional outcomes (adjusted odds ratio [AOR] 2.17; 95% confidence interval [CI] 1.54-3.07; p < 0.01).
Discussion: Fluid retention in post-thrombectomy stroke patients in the ICU is associated with poorer functional and neurological outcomes. Consequently, fluid retention emerges as an additional potential predictor for post-intervention stroke outcomes. Our findings provide an initial indication that preventing excessive fluid retention in stroke patients after endovascular thrombectomy could be beneficial for both functional and neurological recovery. Therefore, fluid retention might be an element to consider in optimizing fluid management for stroke patients.
{"title":"Fluid excess on intensive care unit after mechanical thrombectomy after acute ischemic stroke is associated with unfavorable neurological and functional outcomes: An observational cohort study.","authors":"Maximilian Schell, Christina Mayer, Marcel Seungsu Woo, Hannes Leischner, Marlene Fischer, Jörn Grensemann, Stefan Kluge, Patrick Czorlich, Christian Gerloff, Jens Fiehler, Götz Thomalla, Fabian Flottmann, Nils Schweingruber","doi":"10.1177/23969873241271642","DOIUrl":"https://doi.org/10.1177/23969873241271642","url":null,"abstract":"<p><strong>Introduction: </strong>Endovascular thrombectomy stands as a pivotal component in the standard care for patients experiencing acute ischemic stroke with large vessel occlusion. Subsequent care for patients often extends to a neurological intensive care unit. While fluid management is integral to intensive care, the association between early fluid balance and neurological and functional outcomes post-thrombectomy has not yet been thoroughly investigated.</p><p><strong>Methods: </strong>In a retrospective analysis of an observational, single-center study spanning from 2015 to 2021 at the University Medical Center Hamburg-Eppendorf, Germany, we enrolled stroke patients who underwent thrombectomy and received subsequent treatment in the ICU. Unfavorable functional and neurological outcome was defined as a mRS > 2 on day 90 after admission (mRS d90) or NIHSS > 5 at discharge, respectively. A multivariate regression model, adjusting for confounders, utilized the average fluid balance in the first 5 days to predict outcomes. Patients were dichotomized by their average fluid balance (>1 L vs <1 L) within the first 5 days, and a multivariate mRS d90 shift analysis was conducted after adjusting for covariates.</p><p><strong>Results: </strong>Between 2015 and 2021, 1252 patients underwent thrombectomy, and 553 patients met the inclusion criteria (299 women [54%]). Unfavorable functional outcome was significantly associated with a higher daily average fluid balance in the first 5 days in the ICU (mRS d90 ⩽ 2: 0.3 ± 0.5 L, mRS d90 > 2: 0.7 ± 0.7 L, <i>p</i> = 0.02). The same association was observed for the NIHSS at discharge (NIHSS ⩽ 5: 0.3 ± 0.5 L; NIHSS > 5: 0.6 ± 0.6 L; <i>p</i> = 0.03). The mRS d90 shift analysis revealed significance for patients with an average fluid balance <1 L for better functional outcomes (adjusted odds ratio [AOR] 2.17; 95% confidence interval [CI] 1.54-3.07; <i>p</i> < 0.01).</p><p><strong>Discussion: </strong>Fluid retention in post-thrombectomy stroke patients in the ICU is associated with poorer functional and neurological outcomes. Consequently, fluid retention emerges as an additional potential predictor for post-intervention stroke outcomes. Our findings provide an initial indication that preventing excessive fluid retention in stroke patients after endovascular thrombectomy could be beneficial for both functional and neurological recovery. Therefore, fluid retention might be an element to consider in optimizing fluid management for stroke patients.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":5.8,"publicationDate":"2024-08-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141989192","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}