Pub Date : 2024-07-22DOI: 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
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":"<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","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":5.8,"publicationDate":"2024-07-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","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":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-25DOI: 10.1177/23969873241263402
Farah Wahbeh, Cenai Zhang, Morin Beyeler, Jed H Kaiser, Vanessa Liao, Anokhi Pawar, Hooman Kamel, Babak B Navi
Introduction: Atrial fibrillation (AF) and cancer are each associated with worse outcomes in patients with acute ischemic stroke (AIS). Few studies have evaluated the impact of AF on outcomes of cancer-related stroke.
Patients and methods: We conducted a retrospective cross-sectional study using the 2016-2019 National Inpatient Sample, identifying all hospitalizations with diagnosis codes for cancer and AIS. The primary exposure was a diagnosis of AF. The primary outcome was in-hospital mortality. The secondary outcomes were length-of-stay and discharge to non-home locations. We used multiple logistic and linear regression models, adjusted for age, gender, race-ethnicity, and the Charlson Comorbidity Index, to examine the association between AF and study outcomes.
Results: Among 150,200 hospitalizations with diagnoses of cancer and AIS (mean age 72 years, 53% male), 40,084 (26.7%) included comorbid AF. Compared to hospitalizations without AF, hospitalizations with AF had higher rates of in-hospital mortality (14.8% [95% CI, 14.0%-15.6%] vs 12.1% [95% CI, 11.6%-12.5%]) and non-home discharge disposition (83.5% [95% CI, 82.7%-84.3%] vs 75.1% [95% CI, 74.5%-75.7%]) as well as longer mean length-of-stay (8.4 days [95% CI, 8.2-8.6 days] vs 8.2 days [95% CI, 8.0-8.3 days]). In multivariable analyses, AF remained independently associated with higher odds of in-hospital mortality (adjusted odds ratio [aOR], 1.34; 95% CI, 1.24-1.46), non-home discharge disposition (aOR, 1.32; 95% CI, 1.23-1.42), and longer length-of-stay (adjusted mean difference, 13.7%; 95% CI, 10.9%-16.7%).
Discussion and conclusion: In cancer-related AIS, comorbid AF is associated with worse short-term outcomes, including higher odds for in-hospital mortality, poor discharge disposition, and longer hospital stays.
{"title":"Atrial fibrillation and short-term outcomes after cancer-related ischemic stroke.","authors":"Farah Wahbeh, Cenai Zhang, Morin Beyeler, Jed H Kaiser, Vanessa Liao, Anokhi Pawar, Hooman Kamel, Babak B Navi","doi":"10.1177/23969873241263402","DOIUrl":"https://doi.org/10.1177/23969873241263402","url":null,"abstract":"<p><strong>Introduction: </strong>Atrial fibrillation (AF) and cancer are each associated with worse outcomes in patients with acute ischemic stroke (AIS). Few studies have evaluated the impact of AF on outcomes of cancer-related stroke.</p><p><strong>Patients and methods: </strong>We conducted a retrospective cross-sectional study using the 2016-2019 National Inpatient Sample, identifying all hospitalizations with diagnosis codes for cancer and AIS. The primary exposure was a diagnosis of AF. The primary outcome was in-hospital mortality. The secondary outcomes were length-of-stay and discharge to non-home locations. We used multiple logistic and linear regression models, adjusted for age, gender, race-ethnicity, and the Charlson Comorbidity Index, to examine the association between AF and study outcomes.</p><p><strong>Results: </strong>Among 150,200 hospitalizations with diagnoses of cancer and AIS (mean age 72 years, 53% male), 40,084 (26.7%) included comorbid AF. Compared to hospitalizations without AF, hospitalizations with AF had higher rates of in-hospital mortality (14.8% [95% CI, 14.0%-15.6%] vs 12.1% [95% CI, 11.6%-12.5%]) and non-home discharge disposition (83.5% [95% CI, 82.7%-84.3%] vs 75.1% [95% CI, 74.5%-75.7%]) as well as longer mean length-of-stay (8.4 days [95% CI, 8.2-8.6 days] vs 8.2 days [95% CI, 8.0-8.3 days]). In multivariable analyses, AF remained independently associated with higher odds of in-hospital mortality (adjusted odds ratio [aOR], 1.34; 95% CI, 1.24-1.46), non-home discharge disposition (aOR, 1.32; 95% CI, 1.23-1.42), and longer length-of-stay (adjusted mean difference, 13.7%; 95% CI, 10.9%-16.7%).</p><p><strong>Discussion and conclusion: </strong>In cancer-related AIS, comorbid AF is associated with worse short-term outcomes, including higher odds for in-hospital mortality, poor discharge disposition, and longer hospital stays.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":5.8,"publicationDate":"2024-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141447307","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 : 2024-06-25DOI: 10.1177/23969873241263201
Gabriel García-Alcántara, Cristina Moreno-López, Rodrigo López-Rebolledo, Pablo Lorenzo-Barreto, Patricia Garay-Albízuri, Beatriz Martínez-García, Ana Llanes, Daniel Pérez-Gil, Juan Luis Chico, Rocío Vera-Lechuga, Sebastián García-Madrona, Consuelo Matute-Lozano, Alicia De Felipe-Mimbrera, Jaime Masjuan, Antonio Cruz-Culebras
Introduction: This study aimed to describe and analyze the rate of clot migration of vessel thrombosis to distal segments in patients with acute ischemic stroke (AIS) who received intravenous thrombolysis (IVT) with tenecteplase (TNK) and alteplase (ALT) before mechanical thrombectomy (MT). In addition, we aimed to determine the relationship between thrombus migration and functional prognosis.
Methods: This study followed the STROBE reporting guidelines. We performed a retrospective analysis of a series of patients from November 2017 to April 2023 with an AIS with thrombosis on CT imaging, treated with IVT (TNK or ALT, split into two distinct groups) prior to mechanical thrombectomy.
Results: Two hundred and fifty-six patients with large vessel occlusion (LVO) were included. Ninety-six had received TNK. One hundred and sixty had received ALT. Of the 96 TNK patients, 25 experienced either complete recanalization (n = 3) or thrombus migration (n = 22). Of the 160 ALT patients, 20 experienced either complete recanalization (n = 6) or thrombus migration (n = 14). The difference being statistically substantial for the thrombus migration rate (OR = 3.61, 95% confidence interval: 1.63; 7.98). Migration to an irretrievable very distal segment occurred in four (4%) patients with TNK and in three patients (2%) with ALT (p > 0.05). Thrombus migration was not significantly associated to a different functional prognosis, measured through Rankin scale after 3 months (OR = 0.44, 95% confidence interval: 0.17; 1.12).
Conclusion: The use of TNK over ALT as a fibrinolytic agent is associated with a higher thrombus migration rate. The migration of thrombi to distal segments, which are theoretically less accessible for mechanical thrombectomy, did not result in worse clinical outcomes.
{"title":"Clot migration in patients treated with tenecteplase versus alteplase before mechanical thrombectomy.","authors":"Gabriel García-Alcántara, Cristina Moreno-López, Rodrigo López-Rebolledo, Pablo Lorenzo-Barreto, Patricia Garay-Albízuri, Beatriz Martínez-García, Ana Llanes, Daniel Pérez-Gil, Juan Luis Chico, Rocío Vera-Lechuga, Sebastián García-Madrona, Consuelo Matute-Lozano, Alicia De Felipe-Mimbrera, Jaime Masjuan, Antonio Cruz-Culebras","doi":"10.1177/23969873241263201","DOIUrl":"https://doi.org/10.1177/23969873241263201","url":null,"abstract":"<p><strong>Introduction: </strong>This study aimed to describe and analyze the rate of clot migration of vessel thrombosis to distal segments in patients with acute ischemic stroke (AIS) who received intravenous thrombolysis (IVT) with tenecteplase (TNK) and alteplase (ALT) before mechanical thrombectomy (MT). In addition, we aimed to determine the relationship between thrombus migration and functional prognosis.</p><p><strong>Methods: </strong>This study followed the STROBE reporting guidelines. We performed a retrospective analysis of a series of patients from November 2017 to April 2023 with an AIS with thrombosis on CT imaging, treated with IVT (TNK or ALT, split into two distinct groups) prior to mechanical thrombectomy.</p><p><strong>Results: </strong>Two hundred and fifty-six patients with large vessel occlusion (LVO) were included. Ninety-six had received TNK. One hundred and sixty had received ALT. Of the 96 TNK patients, 25 experienced either complete recanalization (<i>n</i> = 3) or thrombus migration (<i>n</i> = 22). Of the 160 ALT patients, 20 experienced either complete recanalization (<i>n</i> = 6) or thrombus migration (<i>n</i> = 14). The difference being statistically substantial for the thrombus migration rate (OR = 3.61, 95% confidence interval: 1.63; 7.98). Migration to an irretrievable very distal segment occurred in four (4%) patients with TNK and in three patients (2%) with ALT (<i>p</i> > 0.05). Thrombus migration was not significantly associated to a different functional prognosis, measured through Rankin scale after 3 months (OR = 0.44, 95% confidence interval: 0.17; 1.12).</p><p><strong>Conclusion: </strong>The use of TNK over ALT as a fibrinolytic agent is associated with a higher thrombus migration rate. The migration of thrombi to distal segments, which are theoretically less accessible for mechanical thrombectomy, did not result in worse clinical outcomes.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":5.8,"publicationDate":"2024-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141447308","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 : 2024-06-16DOI: 10.1177/23969873241260154
Yutong Chen, Cyprien A Rivier, Samantha A Mora, Victor Torres Lopez, Sam Payabvash, Kevin N Sheth, Andreas Harloff, Guido J Falcone, Jonathan Rosand, Ernst Mayerhofer, Christopher D Anderson
Background: Predicting functional impairment after intracerebral hemorrhage (ICH) provides valuable information for planning of patient care and rehabilitation strategies. Current prognostic tools are limited in making long term predictions and require multiple expert-defined inputs and interpretation that make their clinical implementation challenging. This study aimed to predict long term functional impairment of ICH patients from admission non-contrast CT scans, leveraging deep learning models in a survival analysis framework.
Methods: We used the admission non-contrast CT scans from 882 patients from the Massachusetts General Hospital ICH Study for training, hyperparameter optimization, and model selection, and 146 patients from the Yale New Haven ICH Study for external validation of a deep learning model predicting functional outcome. Disability (modified Rankin scale [mRS] > 2), severe disability (mRS > 4), and dependent living status were assessed via telephone interviews after 6, 12, and 24 months. The prediction methods were evaluated by the c-index and compared with ICH score and FUNC score.
Results: Using non-contrast CT, our deep learning model achieved higher prediction accuracy of post-ICH dependent living, disability, and severe disability by 6, 12, and 24 months (c-index 0.742 [95% CI -0.700 to 0.778], 0.712 [95% CI -0.674 to 0.752], 0.779 [95% CI -0.733 to 0.832] respectively) compared with the ICH score (c-index 0.673 [95% CI -0.662 to 0.688], 0.647 [95% CI -0.637 to 0.661] and 0.697 [95% CI -0.675 to 0.717]) and FUNC score (c-index 0.701 [95% CI- 0.698 to 0.723], 0.668 [95% CI -0.657 to 0.680] and 0.727 [95% CI -0.708 to 0.753]). In the external independent Yale-ICH cohort, similar performance metrics were obtained for disability and severe disability (c-index 0.725 [95% CI -0.673 to 0.781] and 0.747 [95% CI -0.676 to 0.807], respectively). Similar AUC of predicting each outcome at 6 months, 1 and 2 years after ICH was achieved compared with ICH score and FUNC score.
Conclusion: We developed a generalizable deep learning model to predict onset of dependent living and disability after ICH, which could help to guide treatment decisions, advise relatives in the acute setting, optimize rehabilitation strategies, and anticipate long-term care needs.
背景:预测脑出血(ICH)后的功能障碍可为规划患者护理和康复策略提供有价值的信息。目前的预后工具在进行长期预测方面存在局限性,而且需要多个专家定义的输入和解释,这使其在临床上的应用具有挑战性。本研究旨在利用生存分析框架中的深度学习模型,通过入院非对比 CT 扫描预测 ICH 患者的长期功能障碍:我们使用麻省总医院 ICH 研究中 882 名患者的入院非对比 CT 扫描结果进行训练、超参数优化和模型选择,并使用耶鲁纽黑文 ICH 研究中 146 名患者的扫描结果对预测功能结果的深度学习模型进行外部验证。在 6 个月、12 个月和 24 个月后,通过电话访谈对残疾(改良朗肯量表 [mRS] > 2)、严重残疾(mRS > 4)和依赖性生活状况进行评估。预测方法通过 c 指数进行评估,并与 ICH 评分和 FUNC 评分进行比较:使用非对比 CT,我们的深度学习模型在 6、12 和 24 个月后对 ICH 后依赖性生活、残疾和严重残疾的预测准确率更高(c 指数分别为 0.742 [95% CI -0.700 to 0.778]、0.712 [95% CI -0.674 to 0.752]、0.779 [95% CI -0.733 to 0.832])。832])相比(c-指数分别为 0.673 [95% CI -0.662 to 0.688]、0.647 [95% CI -0.637 to 0.661] 和 0.697 [95% CI -0.675至0.717])和FUNC评分(c指数为0.701[95% CI- 0.698至0.723]、0.668[95% CI -0.657 至0.680]和0.727[95% CI -0.708 至0.753])。在外部独立的 Yale-ICH 队列中,残疾和严重残疾的性能指标相似(c 指数分别为 0.725 [95% CI -0.673 至 0.781] 和 0.747 [95% CI -0.676 至 0.807])。与ICH评分和FUNC评分相比,预测ICH后6个月、1年和2年的各项结果的AUC相似:我们开发了一种可推广的深度学习模型来预测 ICH 后依赖性生活和残疾的发生,这有助于指导治疗决策、在急性期为亲属提供建议、优化康复策略以及预测长期护理需求。
{"title":"Deep learning survival model predicts outcome after intracerebral hemorrhage from initial CT scan.","authors":"Yutong Chen, Cyprien A Rivier, Samantha A Mora, Victor Torres Lopez, Sam Payabvash, Kevin N Sheth, Andreas Harloff, Guido J Falcone, Jonathan Rosand, Ernst Mayerhofer, Christopher D Anderson","doi":"10.1177/23969873241260154","DOIUrl":"10.1177/23969873241260154","url":null,"abstract":"<p><strong>Background: </strong>Predicting functional impairment after intracerebral hemorrhage (ICH) provides valuable information for planning of patient care and rehabilitation strategies. Current prognostic tools are limited in making long term predictions and require multiple expert-defined inputs and interpretation that make their clinical implementation challenging. This study aimed to predict long term functional impairment of ICH patients from admission non-contrast CT scans, leveraging deep learning models in a survival analysis framework.</p><p><strong>Methods: </strong>We used the admission non-contrast CT scans from 882 patients from the Massachusetts General Hospital ICH Study for training, hyperparameter optimization, and model selection, and 146 patients from the Yale New Haven ICH Study for external validation of a deep learning model predicting functional outcome. Disability (modified Rankin scale [mRS] > 2), severe disability (mRS > 4), and dependent living status were assessed via telephone interviews after 6, 12, and 24 months. The prediction methods were evaluated by the c-index and compared with ICH score and FUNC score.</p><p><strong>Results: </strong>Using non-contrast CT, our deep learning model achieved higher prediction accuracy of post-ICH dependent living, disability, and severe disability by 6, 12, and 24 months (c-index 0.742 [95% CI -0.700 to 0.778], 0.712 [95% CI -0.674 to 0.752], 0.779 [95% CI -0.733 to 0.832] respectively) compared with the ICH score (c-index 0.673 [95% CI -0.662 to 0.688], 0.647 [95% CI -0.637 to 0.661] and 0.697 [95% CI -0.675 to 0.717]) and FUNC score (c-index 0.701 [95% CI- 0.698 to 0.723], 0.668 [95% CI -0.657 to 0.680] and 0.727 [95% CI -0.708 to 0.753]). In the external independent Yale-ICH cohort, similar performance metrics were obtained for disability and severe disability (c-index 0.725 [95% CI -0.673 to 0.781] and 0.747 [95% CI -0.676 to 0.807], respectively). Similar AUC of predicting each outcome at 6 months, 1 and 2 years after ICH was achieved compared with ICH score and FUNC score.</p><p><strong>Conclusion: </strong>We developed a generalizable deep learning model to predict onset of dependent living and disability after ICH, which could help to guide treatment decisions, advise relatives in the acute setting, optimize rehabilitation strategies, and anticipate long-term care needs.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":6.1,"publicationDate":"2024-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141332188","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 : 2024-06-14DOI: 10.1177/23969873241260956
Frederik Pagh Bredahl Kristensen, Helene Matilde Lundsgaard Svane, Kristina Laugesen, Sofie Kejlberg Al-Mashhadi, Diana Hedevang Christensen, Henrik Toft Sørensen, Nils Skajaa
Introduction: The prognosis for stroke patients with type 2 diabetes mellitus (T2DM) remains poorly understood. We examined the risk of mortality and stroke recurrence in stroke patients with T2DM and stroke patients without diabetes.
Patients and methods: We conducted a population-based cohort study including all patients diagnosed with a first-time ischemic stroke (n = 131,594) or intracerebral hemorrhage (ICH, n = 15,492) in Denmark, 2005-2021. Patients with T2DM were identified using hospital diagnosis codes and glucose-lowering drug prescriptions. We calculated risks, risk differences, and risk ratios, standardized by age, sex, and calendar year of stroke admission.
Results: Following ischemic stroke, the 5-year standardized mortality was 46.1% for patients with T2DM and 35.4% for patients without diabetes (standardized risk difference: 10.7% [95% CI 9.9-11.6]; risk ratio: 1.3 [95% CI 1.3-1.3]). The 5-year risk of recurrence following ischemic stroke was 12.7% for patients with T2DM and 11.3% for those without diabetes (risk difference: 1.4% [95% CI 0.9-2.0]; risk ratio: 1.1 [95% CI 1.1-1.2]). Following ICH, the 5-year mortality was 62.8% for patients with T2DM and 53.0% for patients without diabetes (risk difference: 9.8% [95% CI 7.2-12.4)]; risk ratio: 1.2 [95% CI 1.1-1.2]). The 5-year risk of recurrence after ICH was 9.1% for patients with T2DM and 9.7% for patients without diabetes.
Discussion and conclusion: Stroke patients with T2DM were at increased risk of mortality. The risk of stroke recurrence was slightly higher for ischemic stroke patients with T2DM than patients without diabetes, while no difference was observed among ICH patients.
简介对患有 2 型糖尿病(T2DM)的卒中患者的预后仍然知之甚少。我们研究了患有 T2DM 的脑卒中患者和未患有糖尿病的脑卒中患者的死亡率和脑卒中复发风险:我们开展了一项基于人群的队列研究,研究对象包括 2005-2021 年期间在丹麦确诊为首次缺血性中风(n = 131,594 例)或脑内出血(ICH,n = 15,492 例)的所有患者。我们通过医院诊断代码和降糖药物处方确定了 T2DM 患者。我们计算了风险、风险差异和风险比,并按年龄、性别和中风入院日历年进行了标准化:结果:缺血性脑卒中发生后,T2DM 患者的 5 年标准化死亡率为 46.1%,非糖尿病患者为 35.4%(标准化风险差异为 10.7% [95% C]):10.7% [95% CI 9.9-11.6];风险比:1.3 [95% CI 1.3-1.3])。T2DM 患者缺血性卒中后的 5 年复发风险为 12.7%,非糖尿病患者为 11.3%(风险差异:1.4% [95% CI 0.9-2.0];风险比:1.1 [95% CI 1.1-1.2])。发生 ICH 后,T2DM 患者的 5 年死亡率为 62.8%,非糖尿病患者为 53.0%(风险差异:9.8% [95% CI 7.2-12.4];风险比:1.2 [95% CI 1.1-1.2])。T2DM患者ICH后5年复发风险为9.1%,非糖尿病患者为9.7%:讨论与结论:T2DM 患者的死亡风险增加。T2DM患者的卒中复发风险略高于非糖尿病患者,而在ICH患者中未观察到差异。
{"title":"Risk of mortality and recurrence after first-time stroke among patients with type 2 diabetes: A Danish nationwide cohort study.","authors":"Frederik Pagh Bredahl Kristensen, Helene Matilde Lundsgaard Svane, Kristina Laugesen, Sofie Kejlberg Al-Mashhadi, Diana Hedevang Christensen, Henrik Toft Sørensen, Nils Skajaa","doi":"10.1177/23969873241260956","DOIUrl":"https://doi.org/10.1177/23969873241260956","url":null,"abstract":"<p><strong>Introduction: </strong>The prognosis for stroke patients with type 2 diabetes mellitus (T2DM) remains poorly understood. We examined the risk of mortality and stroke recurrence in stroke patients with T2DM and stroke patients without diabetes.</p><p><strong>Patients and methods: </strong>We conducted a population-based cohort study including all patients diagnosed with a first-time ischemic stroke (<i>n</i> = 131,594) or intracerebral hemorrhage (ICH, <i>n</i> = 15,492) in Denmark, 2005-2021. Patients with T2DM were identified using hospital diagnosis codes and glucose-lowering drug prescriptions. We calculated risks, risk differences, and risk ratios, standardized by age, sex, and calendar year of stroke admission.</p><p><strong>Results: </strong>Following ischemic stroke, the 5-year standardized mortality was 46.1% for patients with T2DM and 35.4% for patients without diabetes (standardized risk difference: 10.7% [95% CI 9.9-11.6]; risk ratio: 1.3 [95% CI 1.3-1.3]). The 5-year risk of recurrence following ischemic stroke was 12.7% for patients with T2DM and 11.3% for those without diabetes (risk difference: 1.4% [95% CI 0.9-2.0]; risk ratio: 1.1 [95% CI 1.1-1.2]). Following ICH, the 5-year mortality was 62.8% for patients with T2DM and 53.0% for patients without diabetes (risk difference: 9.8% [95% CI 7.2-12.4)]; risk ratio: 1.2 [95% CI 1.1-1.2]). The 5-year risk of recurrence after ICH was 9.1% for patients with T2DM and 9.7% for patients without diabetes.</p><p><strong>Discussion and conclusion: </strong>Stroke patients with T2DM were at increased risk of mortality. The risk of stroke recurrence was slightly higher for ischemic stroke patients with T2DM than patients without diabetes, while no difference was observed among ICH patients.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":6.1,"publicationDate":"2024-06-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141321795","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 : 2024-06-14DOI: 10.1177/23969873241261011
Mihae Roland, Ann-Sofie Rudberg, Kristina Alexanderson, Christina Sjöstrand
Introduction: The aim was to determine ischemic stroke patients' sickness absence and disability pension before and after stroke, and compare these to that of matched references.
Patients and methods: All working-aged individuals (aged 18-61) in Sweden with incident ischemic stroke in year 2000, 2005, 2010, or 2015, respectively, and five population-based matched references to each stroke patient. Each cohort was followed 1 year prior stroke and 3 years after. We calculated rates and mean days of sickness absence and disability pension among stroke patients and references and computed trajectories of absence days with predictors of high sickness absence and disability pension.
Results: Number of patients with incident ischemic stroke in 2000 (N = 2728), 2005 (N = 2738), 2010 (N = 2767), and 2015 (N = 2531). Mean stroke age was 53 years and rate of men was 64%. Mortality rate within 12 months after stroke date decreased from 8.1% in 2000 to 4.8% in 2015. Sickness absence for patients was 31.1% in the year prior their stroke, versus 13.7% for references, both groups mainly due to mental and musculoskeletal diagnoses. Factors associated with future high mean number of sickness absence and disability pension days were elementary educational level; adjusted OR (CI) 3.47(2.38-5.05), being single; 1.67(1.29-2.16), female sex 1.72(1.31-2.26), diabetes; 1.86(1.18-2.92), and aged >50; 2.25(1.69-2.98).
Discussion and conclusion: Ischemic stroke patients have more absence days compared to matched references even before the stroke, mainly related to mental and musculoskeletal diagnoses. Future research should address the impact of efficient stroke treatment on sickness absence and disability pension.
{"title":"Sickness absence and disability pension patterns before and after ischemic stroke: A Swedish longitudinal cohort study with matched references.","authors":"Mihae Roland, Ann-Sofie Rudberg, Kristina Alexanderson, Christina Sjöstrand","doi":"10.1177/23969873241261011","DOIUrl":"https://doi.org/10.1177/23969873241261011","url":null,"abstract":"<p><strong>Introduction: </strong>The aim was to determine ischemic stroke patients' sickness absence and disability pension before and after stroke, and compare these to that of matched references.</p><p><strong>Patients and methods: </strong>All working-aged individuals (aged 18-61) in Sweden with incident ischemic stroke in year 2000, 2005, 2010, or 2015, respectively, and five population-based matched references to each stroke patient. Each cohort was followed 1 year prior stroke and 3 years after. We calculated rates and mean days of sickness absence and disability pension among stroke patients and references and computed trajectories of absence days with predictors of high sickness absence and disability pension.</p><p><strong>Results: </strong>Number of patients with incident ischemic stroke in 2000 (<i>N</i> = 2728), 2005 (<i>N</i> = 2738), 2010 (<i>N</i> = 2767), and 2015 (<i>N</i> = 2531). Mean stroke age was 53 years and rate of men was 64%. Mortality rate within 12 months after stroke date decreased from 8.1% in 2000 to 4.8% in 2015. Sickness absence for patients was 31.1% in the year prior their stroke, versus 13.7% for references, both groups mainly due to mental and musculoskeletal diagnoses. Factors associated with future high mean number of sickness absence and disability pension days were elementary educational level; adjusted OR (CI) 3.47(2.38-5.05), being single; 1.67(1.29-2.16), female sex 1.72(1.31-2.26), diabetes; 1.86(1.18-2.92), and aged >50; 2.25(1.69-2.98).</p><p><strong>Discussion and conclusion: </strong>Ischemic stroke patients have more absence days compared to matched references even before the stroke, mainly related to mental and musculoskeletal diagnoses. Future research should address the impact of efficient stroke treatment on sickness absence and disability pension.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":6.1,"publicationDate":"2024-06-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141321796","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 : 2024-06-13DOI: 10.1177/23969873241259561
Neal S Parikh, Cenai Zhang, Samuel S Bruce, Santosh B Murthy, Russell Rosenblatt, Ava L Liberman, Vanessa Liao, Jed H Kaiser, Babak B Navi, Costantino Iadecola, Hooman Kamel
Background: Cirrhosis is associated with an increased risk of hemorrhagic stroke. Liver fibrosis, typically a silent condition, is antecedent to cirrhosis. The objective of this study was to test the hypothesis that elevated Fibrosis-4 (FIB-4) index, indicating a high probability of liver fibrosis, is associated with an increased risk of hemorrhagic stroke.
Methods: We performed a cohort analysis of the prospective United Kingdom Biobank cohort study. Participants 40-69 years old were enrolled between 2007 and 2010 and had available follow-up data until March 1, 2018. We excluded participants with prevalent hemorrhagic stroke or thrombocytopenia. High probability of liver fibrosis was defined as having a value >2.67 of the validated FIB-4 index. The primary outcome was hemorrhagic stroke (intracerebral or subarachnoid hemorrhage), defined based on hospitalization and death registry data. Secondary outcomes were intracerebral and subarachnoid hemorrhage, separately. We used Cox proportional hazards models to evaluate the association of FIB-4 index >2.67 with hemorrhagic stroke while adjusting for potential confounders including hypertension, alcohol use, and antithrombotic use.
Results: Among 452,994 participants (mean age, 57 years; 54% women), approximately 2% had FIB-4 index >2.67, and 1241 developed hemorrhagic stroke. In adjusted models, FIB-4 index >2.67 was associated with an increased risk of hemorrhagic stroke (HR, 2.0; 95% CI, 1.6-2.6). Results were similar for intracerebral hemorrhage (HR, 2.0; 95% CI, 1.5-2.7) and subarachnoid hemorrhage (HR, 2.2; 95% CI, 1.5-3.5) individually.
Conclusions: Elevated FIB-4 index was associated with an increased risk of hemorrhagic stroke.
{"title":"Association between elevated fibrosis-4 index of liver fibrosis and risk of hemorrhagic stroke.","authors":"Neal S Parikh, Cenai Zhang, Samuel S Bruce, Santosh B Murthy, Russell Rosenblatt, Ava L Liberman, Vanessa Liao, Jed H Kaiser, Babak B Navi, Costantino Iadecola, Hooman Kamel","doi":"10.1177/23969873241259561","DOIUrl":"https://doi.org/10.1177/23969873241259561","url":null,"abstract":"<p><strong>Background: </strong>Cirrhosis is associated with an increased risk of hemorrhagic stroke. Liver fibrosis, typically a silent condition, is antecedent to cirrhosis. The objective of this study was to test the hypothesis that elevated Fibrosis-4 (FIB-4) index, indicating a high probability of liver fibrosis, is associated with an increased risk of hemorrhagic stroke.</p><p><strong>Methods: </strong>We performed a cohort analysis of the prospective United Kingdom Biobank cohort study. Participants 40-69 years old were enrolled between 2007 and 2010 and had available follow-up data until March 1, 2018. We excluded participants with prevalent hemorrhagic stroke or thrombocytopenia. High probability of liver fibrosis was defined as having a value >2.67 of the validated FIB-4 index. The primary outcome was hemorrhagic stroke (intracerebral or subarachnoid hemorrhage), defined based on hospitalization and death registry data. Secondary outcomes were intracerebral and subarachnoid hemorrhage, separately. We used Cox proportional hazards models to evaluate the association of FIB-4 index >2.67 with hemorrhagic stroke while adjusting for potential confounders including hypertension, alcohol use, and antithrombotic use.</p><p><strong>Results: </strong>Among 452,994 participants (mean age, 57 years; 54% women), approximately 2% had FIB-4 index >2.67, and 1241 developed hemorrhagic stroke. In adjusted models, FIB-4 index >2.67 was associated with an increased risk of hemorrhagic stroke (HR, 2.0; 95% CI, 1.6-2.6). Results were similar for intracerebral hemorrhage (HR, 2.0; 95% CI, 1.5-2.7) and subarachnoid hemorrhage (HR, 2.2; 95% CI, 1.5-3.5) individually.</p><p><strong>Conclusions: </strong>Elevated FIB-4 index was associated with an increased risk of hemorrhagic stroke.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":6.1,"publicationDate":"2024-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141318598","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 : 2024-06-13DOI: 10.1177/23969873241260538
Aikaterini Theodorou, Ioanna Tsantzali, Maria-Ioanna Stefanou, Simona Sacco, Aristeidis H Katsanos, Ashkan Shoamanesh, Theodoros Karapanayiotides, Ioanna Koutroulou, Polyxeni Stamati, David J Werring, Charlotte Cordonnier, Lina Palaiodimou, Christina Zompola, Efstathios Boviatsis, Lampis Stavrinou, Frantzeska Frantzeskaki, Thorsten Steiner, Andrei V Alexandrov, Georgios P Paraskevas, Georgios Tsivgoulis
Introduction: There are limited data regarding cerebrospinal fluid (CSF) and plasma biomarkers among patients with Cerebral Amyloid Angiopathy (CAA). We sought to investigate the levels of four biomarkers [β-amyloids (Aβ42 and Aβ40), total tau (tau) and phosphorylated tau (p-tau)] in CAA patients compared to healthy controls (HC) and patients with Alzheimer Disease (AD).
Patients and methods: A systematic review and meta-analysis of published studies, including also a 5 year single-center cohort study, with available data on CSF and plasma biomarkers in symptomatic sporadic CAA versus HC and AD was conducted. Biomarkers' comparisons were investigated using random-effects models based on the ratio of mean (RoM) biomarker concentrations. RoM < 1 and RoM > 1 indicate lower and higher biomarker concentration in CAA compared to another population, respectively.
Results: We identified nine cohorts, comprising 327 CAA patients (mean age: 71 ± 5 years; women: 45%) versus 336 HC (mean age: 65 ± 5 years; women: 45%) and 384 AD patients (mean age: 68 ± 3 years; women: 53%) with available data on CSF biomarkers. CSF Aβ42 levels [RoM: 0.47; 95% CI: 0.36-0.62; p < 0.0001], Aβ40 levels [RoM: 0.70; 95% CI: 0.63-0.79; p < 0.0001] and the ratio Aβ42/Aβ40 [RoM: 0.62; 95% CI: 0.39-0.98; p = 0.0438] differentiated CAA from HC. CSF Aβ40 levels [RoM: 0.73; 95% CI: 0.64-0.83; p = 0.0003] differentiated CAA from AD. CSF tau and p-tau levels differentiated CAA from HC [RoM: 1.71; 95% CI: 1.41-2.09; p = 0.0002 and RoM: 1.44; 95% CI: 1.20-1.73; p = 0.0014, respectively] and from AD [RoM: 0.65; 95% CI: 0.58-0.72; p < 0.0001 and RoM: 0.64; 95% CI: 0.57-0.71; p < 0.0001, respectively]. Plasma Aβ42 [RoM: 1.14; 95% CI: 0.89-1.45; p = 0.2079] and Aβ40 [RoM: 1.07; 95% CI: 0.91-1.25; p = 0.3306] levels were comparable between CAA and HC.
Conclusions: CAA is characterized by a distinct CSF biomarker pattern compared to HC and AD. CSF Aβ40 levels are lower in CAA compared to HC and AD, while tau and p-tau levels are higher in CAA compared to HC, but lower in comparison to AD patients.
导言:有关脑淀粉样血管病(CAA)患者脑脊液(CSF)和血浆生物标志物的数据有限。我们试图研究与健康对照组(HC)和阿尔茨海默病(AD)患者相比,CAA 患者脑脊液中四种生物标志物(β-淀粉样蛋白(Aβ42 和 Aβ40)、总 tau(tau)和磷酸化 tau(p-tau))的水平:对已发表的研究(包括一项为期 5 年的单中心队列研究)进行了系统回顾和荟萃分析,这些研究提供了无症状散发性 CAA 与 HC 和 AD 的脑脊液和血浆生物标志物的数据。生物标志物的比较采用基于生物标志物平均浓度比值(RoM)的随机效应模型进行研究。RoM1分别表示与其他人群相比,CAA的生物标志物浓度较低和较高:我们确定了九个队列,包括 327 名 CAA 患者(平均年龄:71 ± 5 岁;女性:45%)与 336 名 HC 患者(平均年龄:65 ± 5 岁;女性:45%)和 384 名 AD 患者(平均年龄:68 ± 3 岁;女性:53%)的 CSF 生物标志物数据。CSF Aβ42 水平[RoM:0.47;95% CI:0.36-0.62;p p = 0.0438]可将 CAA 与 HC 区分开来。CSF Aβ40水平[RoM:0.73;95% CI:0.64-0.83;p = 0.0003]可将CAA与AD区分开来。CSF tau 和 p-tau 水平可将 CAA 与 HC 区分开来 [RoM: 1.71; 95% CI: 1.41-2.09; p = 0.0002 和 RoM: 1.44; 95% CI: 1.20-1.73; p = 0.0014],也可将 CAA 与 AD 区分开来 [RoM: 0.65;95% CI:0.58-0.72;p p = 0.2079]和 Aβ40 [RoM:1.07;95% CI:0.91-1.25;p = 0.3306]水平在 CAA 和 HC 之间相当.结论:结论:与HC和AD相比,CAA具有独特的CSF生物标志物模式。结论:与HC和AD患者相比,CAA患者的CSF Aβ40水平较低,而与HC患者相比,CAA患者的tau和p-tau水平较高,但与AD患者相比较低。
{"title":"CSF and plasma biomarkers in cerebral amyloid angiopathy: A single-center study and a systematic review/meta-analysis.","authors":"Aikaterini Theodorou, Ioanna Tsantzali, Maria-Ioanna Stefanou, Simona Sacco, Aristeidis H Katsanos, Ashkan Shoamanesh, Theodoros Karapanayiotides, Ioanna Koutroulou, Polyxeni Stamati, David J Werring, Charlotte Cordonnier, Lina Palaiodimou, Christina Zompola, Efstathios Boviatsis, Lampis Stavrinou, Frantzeska Frantzeskaki, Thorsten Steiner, Andrei V Alexandrov, Georgios P Paraskevas, Georgios Tsivgoulis","doi":"10.1177/23969873241260538","DOIUrl":"https://doi.org/10.1177/23969873241260538","url":null,"abstract":"<p><strong>Introduction: </strong>There are limited data regarding cerebrospinal fluid (CSF) and plasma biomarkers among patients with Cerebral Amyloid Angiopathy (CAA). We sought to investigate the levels of four biomarkers [β-amyloids (Aβ42 and Aβ40), total tau (tau) and phosphorylated tau (p-tau)] in CAA patients compared to healthy controls (HC) and patients with Alzheimer Disease (AD).</p><p><strong>Patients and methods: </strong>A systematic review and meta-analysis of published studies, including also a 5 year single-center cohort study, with available data on CSF and plasma biomarkers in symptomatic sporadic CAA versus HC and AD was conducted. Biomarkers' comparisons were investigated using random-effects models based on the ratio of mean (RoM) biomarker concentrations. RoM < 1 and RoM > 1 indicate lower and higher biomarker concentration in CAA compared to another population, respectively.</p><p><strong>Results: </strong>We identified nine cohorts, comprising 327 CAA patients (mean age: 71 ± 5 years; women: 45%) versus 336 HC (mean age: 65 ± 5 years; women: 45%) and 384 AD patients (mean age: 68 ± 3 years; women: 53%) with available data on CSF biomarkers. CSF Aβ42 levels [RoM: 0.47; 95% CI: 0.36-0.62; <i>p</i> < 0.0001], Aβ40 levels [RoM: 0.70; 95% CI: 0.63-0.79; <i>p</i> < 0.0001] and the ratio Aβ42/Aβ40 [RoM: 0.62; 95% CI: 0.39-0.98; <i>p</i> = 0.0438] differentiated CAA from HC. CSF Aβ40 levels [RoM: 0.73; 95% CI: 0.64-0.83; <i>p</i> = 0.0003] differentiated CAA from AD. CSF tau and p-tau levels differentiated CAA from HC [RoM: 1.71; 95% CI: 1.41-2.09; <i>p</i> = 0.0002 and RoM: 1.44; 95% CI: 1.20-1.73; <i>p</i> = 0.0014, respectively] and from AD [RoM: 0.65; 95% CI: 0.58-0.72; <i>p</i> < 0.0001 and RoM: 0.64; 95% CI: 0.57-0.71; <i>p</i> < 0.0001, respectively]. Plasma Aβ42 [RoM: 1.14; 95% CI: 0.89-1.45; <i>p</i> = 0.2079] and Aβ40 [RoM: 1.07; 95% CI: 0.91-1.25; <i>p</i> = 0.3306] levels were comparable between CAA and HC.</p><p><strong>Conclusions: </strong>CAA is characterized by a distinct CSF biomarker pattern compared to HC and AD. CSF Aβ40 levels are lower in CAA compared to HC and AD, while tau and p-tau levels are higher in CAA compared to HC, but lower in comparison to AD patients.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":6.1,"publicationDate":"2024-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141311992","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 : 2024-06-13DOI: 10.1177/23969873241255250
Eleonora De Matteis, Raffaele Ornello, Federico De Santis, Matteo Foschi, Michele Romoli, Tiziana Tassinari, Valentina Saia, Silvia Cenciarelli, Chiara Bedetti, Chiara Padiglioni, Bruno Censori, Valentina Puglisi, Luisa Vinciguerra, Maria Guarino, Valentina Barone, Marialuisa Zedde, Ilaria Grisendi, Marina Diomedi, Maria Rosaria Bagnato, Marco Petruzzellis, Domenico Maria Mezzapesa, Pietro Di Viesti, Vincenzo Inchingolo, Manuel Cappellari, Mara Zenorini, Paolo Candelaresi, Vincenzo Andreone, Giuseppe Rinaldi, Alessandra Bavaro, Anna Cavallini, Stefan Moraru, Pietro Querzani, Valeria Terruso, Marina Mannino, Alessandro Pezzini, Giovanni Frisullo, Francesco Muscia, Maurizio Paciaroni, Maria Giulia Mosconi, Andrea Zini, Ruggiero Leone, Carmela Palmieri, Letizia Maria Cupini, Michela Marcon, Rossana Tassi, Enzo Sanzaro, Cristina Paci, Giovanna Viticchi, Daniele Orsucci, Anne Falcou, Susanna Diamanti, Roberto Tarletti, Patrizia Nencini, Eugenia Rota, Federica Nicoletta Sepe, Delfina Ferrandi, Luigi Caputi, Gino Volpi, Salvatore La Spada, Mario Beccia, Claudia Rinaldi, Vincenzo Mastrangelo, Francesco Di Blasio, Paolo Invernizzi, Giuseppe Pelliccioni, Maria Vittoria De Angelis, Laura Bonanni, Giampietro Ruzza, Emanuele Alessandro Caggia, Monia Russo, Agnese Tonon, Maria Cristina Acciarri, Sabrina Anticoli, Cinzia Roberti, Giovanni Manobianca, Gaspare Scaglione, Francesca Pistoia, Alberto Fortini, Antonella De Boni, Alessandra Sanna, Alberto Chiti, Leonardo Barbarini, Marcella Caggiula, Maela Masato, Massimo Del Sette, Francesco Passarelli, Maria Roberta Bongioanni, Danilo Toni, Stefano Ricci, Simona Sacco
Background and purpose: Randomized controlled trials (RCTs) proved the efficacy of short-term dual antiplatelet therapy (DAPT) in secondary prevention of minor ischemic stroke or high-risk transient ischemic attack (TIA). We aimed at evaluating effectiveness and safety of short-term DAPT in real-world, where treatment use is broader than in RCTs.
Methods: READAPT (REAl-life study on short-term Dual Antiplatelet treatment in Patients with ischemic stroke or Transient ischemic attack) (NCT05476081) was an observational multicenter real-world study with a 90-day follow-up. We included patients aged 18+ receiving short-term DAPT soon after ischemic stroke or TIA. No stringent NIHSS and ABCD2 score cut-offs were applied but adherence to guidelines was recommended. Primary effectiveness outcome was stroke (ischemic or hemorrhagic) or death due to vascular causes, primary safety outcome was moderate-to-severe bleeding. Secondary outcomes were the type of ischemic and hemorrhagic events, disability, cause of death, and compliance to treatment.
Results: We included 1920 patients; 69.9% started DAPT after an ischemic stroke; only 8.9% strictly followed entry criteria or procedures of RCTs. Primary effectiveness outcome occurred in 3.9% and primary safety outcome in 0.6% of cases. In total, 3.3% cerebrovascular ischemic recurrences occurred, 0.2% intracerebral hemorrhages, and 2.7% bleedings; 0.2% of patients died due to vascular causes. Patients with NIHSS score ⩽5 and those without acute lesions at neuroimaging had significantly higher primary effectiveness outcomes than their counterparts. Additionally, DAPT start >24 h after symptom onset was associated with a lower likelihood of bleeding.
Conclusions: In real-world, most of the patients who receive DAPT after an ischemic stroke or a TIA do not follow RCTs entry criteria and procedures. Nevertheless, short-term DAPT remains effective and safe in this population. No safety concerns are raised in patients with low-risk TIA, more severe stroke, and delayed treatment start.
{"title":"Beyond RCTs: Short-term dual antiplatelet therapy in secondary prevention of ischemic stroke and transient ischemic attack.","authors":"Eleonora De Matteis, Raffaele Ornello, Federico De Santis, Matteo Foschi, Michele Romoli, Tiziana Tassinari, Valentina Saia, Silvia Cenciarelli, Chiara Bedetti, Chiara Padiglioni, Bruno Censori, Valentina Puglisi, Luisa Vinciguerra, Maria Guarino, Valentina Barone, Marialuisa Zedde, Ilaria Grisendi, Marina Diomedi, Maria Rosaria Bagnato, Marco Petruzzellis, Domenico Maria Mezzapesa, Pietro Di Viesti, Vincenzo Inchingolo, Manuel Cappellari, Mara Zenorini, Paolo Candelaresi, Vincenzo Andreone, Giuseppe Rinaldi, Alessandra Bavaro, Anna Cavallini, Stefan Moraru, Pietro Querzani, Valeria Terruso, Marina Mannino, Alessandro Pezzini, Giovanni Frisullo, Francesco Muscia, Maurizio Paciaroni, Maria Giulia Mosconi, Andrea Zini, Ruggiero Leone, Carmela Palmieri, Letizia Maria Cupini, Michela Marcon, Rossana Tassi, Enzo Sanzaro, Cristina Paci, Giovanna Viticchi, Daniele Orsucci, Anne Falcou, Susanna Diamanti, Roberto Tarletti, Patrizia Nencini, Eugenia Rota, Federica Nicoletta Sepe, Delfina Ferrandi, Luigi Caputi, Gino Volpi, Salvatore La Spada, Mario Beccia, Claudia Rinaldi, Vincenzo Mastrangelo, Francesco Di Blasio, Paolo Invernizzi, Giuseppe Pelliccioni, Maria Vittoria De Angelis, Laura Bonanni, Giampietro Ruzza, Emanuele Alessandro Caggia, Monia Russo, Agnese Tonon, Maria Cristina Acciarri, Sabrina Anticoli, Cinzia Roberti, Giovanni Manobianca, Gaspare Scaglione, Francesca Pistoia, Alberto Fortini, Antonella De Boni, Alessandra Sanna, Alberto Chiti, Leonardo Barbarini, Marcella Caggiula, Maela Masato, Massimo Del Sette, Francesco Passarelli, Maria Roberta Bongioanni, Danilo Toni, Stefano Ricci, Simona Sacco","doi":"10.1177/23969873241255250","DOIUrl":"10.1177/23969873241255250","url":null,"abstract":"<p><strong>Background and purpose: </strong>Randomized controlled trials (RCTs) proved the efficacy of short-term dual antiplatelet therapy (DAPT) in secondary prevention of minor ischemic stroke or high-risk transient ischemic attack (TIA). We aimed at evaluating effectiveness and safety of short-term DAPT in real-world, where treatment use is broader than in RCTs.</p><p><strong>Methods: </strong>READAPT (REAl-life study on short-term Dual Antiplatelet treatment in Patients with ischemic stroke or Transient ischemic attack) (NCT05476081) was an observational multicenter real-world study with a 90-day follow-up. We included patients aged 18+ receiving short-term DAPT soon after ischemic stroke or TIA. No stringent NIHSS and ABCD<sup>2</sup> score cut-offs were applied but adherence to guidelines was recommended. Primary effectiveness outcome was stroke (ischemic or hemorrhagic) or death due to vascular causes, primary safety outcome was moderate-to-severe bleeding. Secondary outcomes were the type of ischemic and hemorrhagic events, disability, cause of death, and compliance to treatment.</p><p><strong>Results: </strong>We included 1920 patients; 69.9% started DAPT after an ischemic stroke; only 8.9% strictly followed entry criteria or procedures of RCTs. Primary effectiveness outcome occurred in 3.9% and primary safety outcome in 0.6% of cases. In total, 3.3% cerebrovascular ischemic recurrences occurred, 0.2% intracerebral hemorrhages, and 2.7% bleedings; 0.2% of patients died due to vascular causes. Patients with NIHSS score ⩽5 and those without acute lesions at neuroimaging had significantly higher primary effectiveness outcomes than their counterparts. Additionally, DAPT start >24 h after symptom onset was associated with a lower likelihood of bleeding.</p><p><strong>Conclusions: </strong>In real-world, most of the patients who receive DAPT after an ischemic stroke or a TIA do not follow RCTs entry criteria and procedures. Nevertheless, short-term DAPT remains effective and safe in this population. No safety concerns are raised in patients with low-risk TIA, more severe stroke, and delayed treatment start.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":5.8,"publicationDate":"2024-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141311991","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 : 2024-06-13DOI: 10.1177/23969873241260965
Alejandro Rodríguez-Vázquez, Carlos Laredo, Luis Reyes, Guillem Dolz, Antonio Doncel-Moriano, Laura Llansó, Salvatore Rudilosso, Laura Llull, Arturo Renú, Sergio Amaro, Ramón Torné, Xabier Urra, Ángel Chamorro
Introduction: Malignant middle cerebral artery infarction (MCI) needs rapid intervention. This study aimed to enhance the prediction of MCI using computed tomography perfusion (CTP) with varied quantitative benchmarks.
Materials and methods: We retrospectively analyzed 253 patients from a single-center registry presenting with acute, severe, proximal large vessel occlusion studied with whole-brain CTP imaging at hospital arrival within the first 24 h of symptoms-onset. MCI was defined by clinical and imaging criteria, including decreased level of consciousness, anisocoria, death due to cerebral edema, or need for decompressive craniectomy, together with midline shift ⩾6 mm, or infarction of more than 50% of the MCA territory. The predictive accuracy of baseline ASPECTS and CTP quantifications for MCI was assessed by receiver operating characteristic (ROC) area under the curve (AUC) while F-score was calculated as an indicator of precision and sensitivity.
Results: Sixty-three out of 253 patients (25%) fulfilled MCI criteria and had worse clinical and imaging results than the non-MCI group. The capacity to predict MCI was lower for baseline ASPECTS (AUC 0.83, F-score 0.52, Youden's index 6), than with perfusion-based measures: relative cerebral blood volume threshold <40% (AUC 0.87, F-score 0.71, Youden's index 34 mL) or relative cerebral blood flow threshold <35% (AUC 0.87, F-score 0.62, Youden's index 67 mL). CTP based on rCBV measurements identified twice as many MCI as baseline CT ASPECTS.
Discussion and conclusion: CTP-based quantifications may offer enhanced predictive capabilities for MCI compared to non-contrast baseline CT ASPECTS, potentially improving the monitoring of severe ischemic stroke patients at risk of life-threatening edema and its treatment.
{"title":"Computed tomography perfusion as an early predictor of malignant cerebral infarction.","authors":"Alejandro Rodríguez-Vázquez, Carlos Laredo, Luis Reyes, Guillem Dolz, Antonio Doncel-Moriano, Laura Llansó, Salvatore Rudilosso, Laura Llull, Arturo Renú, Sergio Amaro, Ramón Torné, Xabier Urra, Ángel Chamorro","doi":"10.1177/23969873241260965","DOIUrl":"https://doi.org/10.1177/23969873241260965","url":null,"abstract":"<p><strong>Introduction: </strong>Malignant middle cerebral artery infarction (MCI) needs rapid intervention. This study aimed to enhance the prediction of MCI using computed tomography perfusion (CTP) with varied quantitative benchmarks.</p><p><strong>Materials and methods: </strong>We retrospectively analyzed 253 patients from a single-center registry presenting with acute, severe, proximal large vessel occlusion studied with whole-brain CTP imaging at hospital arrival within the first 24 h of symptoms-onset. MCI was defined by clinical and imaging criteria, including decreased level of consciousness, anisocoria, death due to cerebral edema, or need for decompressive craniectomy, together with midline shift ⩾6 mm, or infarction of more than 50% of the MCA territory. The predictive accuracy of baseline ASPECTS and CTP quantifications for MCI was assessed by receiver operating characteristic (ROC) area under the curve (AUC) while <i>F</i>-score was calculated as an indicator of precision and sensitivity.</p><p><strong>Results: </strong>Sixty-three out of 253 patients (25%) fulfilled MCI criteria and had worse clinical and imaging results than the non-MCI group. The capacity to predict MCI was lower for baseline ASPECTS (AUC 0.83, <i>F</i>-score 0.52, Youden's index 6), than with perfusion-based measures: relative cerebral blood volume threshold <40% (AUC 0.87, <i>F</i>-score 0.71, Youden's index 34 mL) or relative cerebral blood flow threshold <35% (AUC 0.87, <i>F</i>-score 0.62, Youden's index 67 mL). CTP based on rCBV measurements identified twice as many MCI as baseline CT ASPECTS.</p><p><strong>Discussion and conclusion: </strong>CTP-based quantifications may offer enhanced predictive capabilities for MCI compared to non-contrast baseline CT ASPECTS, potentially improving the monitoring of severe ischemic stroke patients at risk of life-threatening edema and its treatment.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":null,"pages":null},"PeriodicalIF":6.1,"publicationDate":"2024-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141318599","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}