A. Dagra, B. Lucke-Wold, Kyle McGrath, Ilyas Mehkri, Y. Mehkri, C. Davidson, Noah J. Gilberstadt, Bobby W. Douglas, B. Hoh
Central retinal artery occlusion (CRAO) is a form of acute ischemic stroke that results in painless vision loss attributable to retinal infarction. A keen understanding of clinical presentation and underlying pathophysiological features is key to timely intervention and development of new treatment modalities. In CRAO, the time between initial insult to presentation is significant because, analogous to ischemic stroke, the duration of ischemia is inversely related to viable retinal tissue. A major challenge in CRAO is delayed presentation, which reduces the amount of salvageable retina. In addition, imaging techniques to effectively identify a retinal penumbra, or retinal tissue that is reversibly damaged, are not well established. To compile this narrative review, we conducted a systematic search of the PubMed database to identify relevant articles on the pathophysiological features and treatment of CRAO, including reviews, meta‐analyses, clinical studies, observational trials, and randomized trials. The search strategy included the following keywords: central retinal artery occlusion, CRAO, treatment, management, review, meta‐analysis, clinical study, observational trial, and randomized trial. We also searched for ongoing clinical trials related to CRAO on ClinicalTrials.gov. The identified articles and studies were then carefully evaluated for their relevance to the topic and used in compiling this review. Intravenous thrombolysis is a compelling therapeutic approach, with current limited data suggesting early intervention (4.5 hours of symptom onset) results in better patient outcomes. However, ongoing trials assessing and comparing different fibrinolytic agents, routes of administration (venous versus arterial), and timing of intervention will provide further insight on the efficacy of this treatment modality. In parallel, development and testing of imaging techniques aimed at quantifying retinal blood flow and assessing tissue viability could improve risk stratification to guide treatment. These can then be used in conjunction to guide use of conventional therapies, neuroprotectants, and thrombolytics for the management of various CRAO presentations that can be effectively deployed in emergency settings. This article provides a narrative review of pathophysiological features, risk factors, and current and emerging management techniques of CRAO.
{"title":"Central Retinal Artery Occlusion: A Review of Pathophysiological Features and Management","authors":"A. Dagra, B. Lucke-Wold, Kyle McGrath, Ilyas Mehkri, Y. Mehkri, C. Davidson, Noah J. Gilberstadt, Bobby W. Douglas, B. Hoh","doi":"10.1161/svin.123.000977","DOIUrl":"https://doi.org/10.1161/svin.123.000977","url":null,"abstract":"Central retinal artery occlusion (CRAO) is a form of acute ischemic stroke that results in painless vision loss attributable to retinal infarction. A keen understanding of clinical presentation and underlying pathophysiological features is key to timely intervention and development of new treatment modalities. In CRAO, the time between initial insult to presentation is significant because, analogous to ischemic stroke, the duration of ischemia is inversely related to viable retinal tissue. A major challenge in CRAO is delayed presentation, which reduces the amount of salvageable retina. In addition, imaging techniques to effectively identify a retinal penumbra, or retinal tissue that is reversibly damaged, are not well established. To compile this narrative review, we conducted a systematic search of the PubMed database to identify relevant articles on the pathophysiological features and treatment of CRAO, including reviews, meta‐analyses, clinical studies, observational trials, and randomized trials. The search strategy included the following keywords: central retinal artery occlusion, CRAO, treatment, management, review, meta‐analysis, clinical study, observational trial, and randomized trial. We also searched for ongoing clinical trials related to CRAO on ClinicalTrials.gov. The identified articles and studies were then carefully evaluated for their relevance to the topic and used in compiling this review. Intravenous thrombolysis is a compelling therapeutic approach, with current limited data suggesting early intervention (4.5 hours of symptom onset) results in better patient outcomes. However, ongoing trials assessing and comparing different fibrinolytic agents, routes of administration (venous versus arterial), and timing of intervention will provide further insight on the efficacy of this treatment modality. In parallel, development and testing of imaging techniques aimed at quantifying retinal blood flow and assessing tissue viability could improve risk stratification to guide treatment. These can then be used in conjunction to guide use of conventional therapies, neuroprotectants, and thrombolytics for the management of various CRAO presentations that can be effectively deployed in emergency settings. This article provides a narrative review of pathophysiological features, risk factors, and current and emerging management techniques of CRAO.","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-08-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42624615","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Acute stroke management has become increasingly complex, incorporating medical, endovascular, and open surgical treatments that are potentially implemented across multiple hospitals for the same patient. Hospitals work in ever‐expanding networks to provide cost‐effective stroke care, balancing capital and labor costs, expertise, and catchment reach. As these systems and care pathways become more complex and attention is placed on the need to protect privacy, the importance of engaging patients and the community in medical decisions that carry forward from one institute to the next has likewise increased. As each node in the care pathway requires a varying degree of patient input and fulfillment of legal requirements, clinicians would benefit from a fundamental understanding of informed consent and contemporary shared decision‐making. While consent is commonly obtained, clinicians may not be aware of how different levels of consent are appropriate depending on the circumstances. In this essay, we explore the origins of informed consent and its relation to contemporary shared decision‐making. We will then review the acute stroke care continuum, and argue when simple consent, informed consent, and shared medical decision‐making ought to be used to ensure that care is delivered in a matter consistent with ethical practice. This framework is one particular approach to decision‐making and consent that we believe is supported by the arguments in this essay. Unless otherwise stated, the medical practice regarding consent discussed herein is applicable to the United States and may vary in other jurisdictions. Furthermore, consent for research is performed under a different paradigm and will not be explored herein.
{"title":"Informed Consent in the Stroke Care Continuum","authors":"Michael A. Rubin, Rachel Aubert","doi":"10.1161/svin.123.000623","DOIUrl":"https://doi.org/10.1161/svin.123.000623","url":null,"abstract":"Acute stroke management has become increasingly complex, incorporating medical, endovascular, and open surgical treatments that are potentially implemented across multiple hospitals for the same patient. Hospitals work in ever‐expanding networks to provide cost‐effective stroke care, balancing capital and labor costs, expertise, and catchment reach. As these systems and care pathways become more complex and attention is placed on the need to protect privacy, the importance of engaging patients and the community in medical decisions that carry forward from one institute to the next has likewise increased. As each node in the care pathway requires a varying degree of patient input and fulfillment of legal requirements, clinicians would benefit from a fundamental understanding of informed consent and contemporary shared decision‐making. While consent is commonly obtained, clinicians may not be aware of how different levels of consent are appropriate depending on the circumstances. In this essay, we explore the origins of informed consent and its relation to contemporary shared decision‐making. We will then review the acute stroke care continuum, and argue when simple consent, informed consent, and shared medical decision‐making ought to be used to ensure that care is delivered in a matter consistent with ethical practice. This framework is one particular approach to decision‐making and consent that we believe is supported by the arguments in this essay. Unless otherwise stated, the medical practice regarding consent discussed herein is applicable to the United States and may vary in other jurisdictions. Furthermore, consent for research is performed under a different paradigm and will not be explored herein.","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-08-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45769480","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sung-Chun Tang, Y. Hsieh, Chun-Jen Lin, Yu-Wei Chen, Kuan-Hung Lin, P. Sung, Meng-Tsang Hsieh, Chih-Wei Tang, Hai-Jui Chu, Kun-Chang Tsai, C. Chou, Cheng-Yu Wei, Shang-Yih Yen, Po-Lin Chen, H. Yeh, L. Chan, S. Sung, Hon-Man Liu, Ching‐Huang Lin, Chung-wei Lee, I‐Hui Lee, Chi‐Jen Chen, Chien-Jen Lin, Yu-Ming Chang, Chang‐Hsien Ou, Yen-Jun Lai, Cheng‐Huai Lin, Chih‐Hao Chen, C. Chou, Lisa M. Lien, H. Chiou, Jiunn‐Tay Lee, J. Jeng
Endovascular thrombectomy (EVT) is the standard therapy for patients with acute ischemic stroke secondary to large‐artery occlusion. In January 2019, the Taiwan Stroke Society established a nationwide TREAT‐AIS (Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke). Here, we provide the study design, current progress, and baseline data of TREAT‐AIS. TREAT‐AIS is a multicenter prospective registration program in Taiwan. Patients aged ≥20 years who underwent EVT for acute ischemic stroke were recruited. The key items on the registration form were divided into general stroke demographics and EVT‐related sections. The main outcome of effectiveness was functional independence (modified Rankin Scale score, 0–2) at 3 months. The influence of sex on post‐EVT outcomes was also analyzed in the presented study. By the end of June 2022, there were 10 medical centers and 9 community hospitals participating in the TREAT‐AIS and a total of 1522 patients (mean±SD age, 71.2±13.6 years; men, 55.6%) being enrolled. The median National Institutes of Health Stroke Scale score on admission was 18 (interquartile range, 12–23). The major cause of stroke was cardioembolism (43.6%), followed by large‐artery atherosclerosis (36.8%) and an undetermined cause (15.4%). Functional independence at 3 months poststroke was achieved in 36.2% of the patients. Male patients were more likely to have functional independence at 3 months compared with female patients (40.4% versus 30.8%; P <0.001). However, the sex difference in functional independence became nonsignificant (odds ratio, 1.12 [95% CI, 0.96–1.46] in men compared with women) after adjusting for age, National Institutes of Health Stroke Scale score at admission, and recanalization status after EVT. This study demonstrated the current progress of the TREAT‐AIS in capturing real‐world EVT data in Taiwan. The TREAT‐AIS will provide valuable insights into the real‐world practice of EVT in patients with acute stroke and the related quality of care in Asian patients.
{"title":"TREAT‐AIS: A Multicenter National Registry","authors":"Sung-Chun Tang, Y. Hsieh, Chun-Jen Lin, Yu-Wei Chen, Kuan-Hung Lin, P. Sung, Meng-Tsang Hsieh, Chih-Wei Tang, Hai-Jui Chu, Kun-Chang Tsai, C. Chou, Cheng-Yu Wei, Shang-Yih Yen, Po-Lin Chen, H. Yeh, L. Chan, S. Sung, Hon-Man Liu, Ching‐Huang Lin, Chung-wei Lee, I‐Hui Lee, Chi‐Jen Chen, Chien-Jen Lin, Yu-Ming Chang, Chang‐Hsien Ou, Yen-Jun Lai, Cheng‐Huai Lin, Chih‐Hao Chen, C. Chou, Lisa M. Lien, H. Chiou, Jiunn‐Tay Lee, J. Jeng","doi":"10.1161/svin.123.000861","DOIUrl":"https://doi.org/10.1161/svin.123.000861","url":null,"abstract":"\u0000 \u0000 Endovascular thrombectomy (EVT) is the standard therapy for patients with acute ischemic stroke secondary to large‐artery occlusion. In January 2019, the Taiwan Stroke Society established a nationwide TREAT‐AIS (Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke). Here, we provide the study design, current progress, and baseline data of TREAT‐AIS.\u0000 \u0000 \u0000 \u0000 TREAT‐AIS is a multicenter prospective registration program in Taiwan. Patients aged ≥20 years who underwent EVT for acute ischemic stroke were recruited. The key items on the registration form were divided into general stroke demographics and EVT‐related sections. The main outcome of effectiveness was functional independence (modified Rankin Scale score, 0–2) at 3 months. The influence of sex on post‐EVT outcomes was also analyzed in the presented study.\u0000 \u0000 \u0000 \u0000 \u0000 By the end of June 2022, there were 10 medical centers and 9 community hospitals participating in the TREAT‐AIS and a total of 1522 patients (mean±SD age, 71.2±13.6 years; men, 55.6%) being enrolled. The median National Institutes of Health Stroke Scale score on admission was 18 (interquartile range, 12–23). The major cause of stroke was cardioembolism (43.6%), followed by large‐artery atherosclerosis (36.8%) and an undetermined cause (15.4%). Functional independence at 3 months poststroke was achieved in 36.2% of the patients. Male patients were more likely to have functional independence at 3 months compared with female patients (40.4% versus 30.8%;\u0000 P\u0000 <0.001). However, the sex difference in functional independence became nonsignificant (odds ratio, 1.12 [95% CI, 0.96–1.46] in men compared with women) after adjusting for age, National Institutes of Health Stroke Scale score at admission, and recanalization status after EVT.\u0000 \u0000 \u0000 \u0000 \u0000 This study demonstrated the current progress of the TREAT‐AIS in capturing real‐world EVT data in Taiwan. The TREAT‐AIS will provide valuable insights into the real‐world practice of EVT in patients with acute stroke and the related quality of care in Asian patients.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-08-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49479251","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
M. Al-Kawaz, Brian Giovanni, Valerie I. Elmalem, M. Fayad, J. Fifi
{"title":"Surgical Exposure and Direct Puncture of a Thrombosed Superior Ophthalmic Vein in an Optic Nerve Sheath Dural Arteriovenous Fistula","authors":"M. Al-Kawaz, Brian Giovanni, Valerie I. Elmalem, M. Fayad, J. Fifi","doi":"10.1161/svin.123.000844","DOIUrl":"https://doi.org/10.1161/svin.123.000844","url":null,"abstract":"","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-08-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49063372","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
L. Dekker, V. Geraedts, J. Hubert, Dion Duijndam, Marcel D.J. Durieux, Loes Janssens, W. Moojen, E. V. van Zwet, M. Wermer, N. Kruyt, I. R. Wijngaard
The Rapid Arterial oCclusion Evaluation (RACE) score can identify patients with anterior circulation large‐vessel occlusion (aLVO) ischemic stroke for transportation to a comprehensive stroke center for endovascular thrombectomy. However, patients with intracranial hemorrhage (ICH) may also benefit from direct transportation to a comprehensive stroke center for neurosurgical treatment. We aimed to assess if the RACE score can distinguish patients with ICH in addition to aLVO stroke from other patients with suspected stroke. We analyzed data from the LPSS (Leiden Prehospital Stroke Study), a multicenter, prospective, observational cohort study in 2 Dutch ambulance regions. Ambulance paramedics documented prehospital observations in all patients aged ≥18 years with suspected stroke. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of a positive RACE score (≥5 points) for a diagnosis of ICH or aLVO stroke, compared with patients with non‐aLVO stroke, transient ischemic attack, or stroke mimic. In addition, we performed a multivariable logistic regression analysis and calculated adjusted odds ratios (ORs). We included 2004 patients with a stroke code, of whom 149 had an ICH, 153 had an aLVO stroke, 687 had a non‐aLVO stroke, 262 had a transient ischemic attack, and 753 had a stroke mimic. Patients with ICH and aLVO stroke more often had a positive RACE score than other patients with suspected stroke (46.2% and 58.0%, respectively, versus 6.4%; P <0.01). A positive RACE score had a sensitivity of 52.7%, a specificity of 93.6%, a positive predictive value of 55.4%, and a negative predictive value of 92.9% for a diagnosis of ICH or aLVO stroke. In multivariable analysis, a positive RACE score had the strongest association with ICH or aLVO stroke (adjusted OR, 10.11 [95% CI, 6.84–14.93]). Our study shows that the RACE score can also identify patients with ICH in addition to aLVO stroke. This emphasizes the potential of the RACE score for improving prehospital triage and allocation of patients with stroke.
{"title":"Prehospital Triage of Intracranial Hemorrhage and Anterior Large‐Vessel Occlusion Ischemic Stroke: Value of the Rapid Arterial Occlusion Evaluation","authors":"L. Dekker, V. Geraedts, J. Hubert, Dion Duijndam, Marcel D.J. Durieux, Loes Janssens, W. Moojen, E. V. van Zwet, M. Wermer, N. Kruyt, I. R. Wijngaard","doi":"10.1161/svin.123.000947","DOIUrl":"https://doi.org/10.1161/svin.123.000947","url":null,"abstract":"\u0000 \u0000 The Rapid Arterial oCclusion Evaluation (RACE) score can identify patients with anterior circulation large‐vessel occlusion (aLVO) ischemic stroke for transportation to a comprehensive stroke center for endovascular thrombectomy. However, patients with intracranial hemorrhage (ICH) may also benefit from direct transportation to a comprehensive stroke center for neurosurgical treatment. We aimed to assess if the RACE score can distinguish patients with ICH in addition to aLVO stroke from other patients with suspected stroke.\u0000 \u0000 \u0000 \u0000 We analyzed data from the LPSS (Leiden Prehospital Stroke Study), a multicenter, prospective, observational cohort study in 2 Dutch ambulance regions. Ambulance paramedics documented prehospital observations in all patients aged ≥18 years with suspected stroke. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of a positive RACE score (≥5 points) for a diagnosis of ICH or aLVO stroke, compared with patients with non‐aLVO stroke, transient ischemic attack, or stroke mimic. In addition, we performed a multivariable logistic regression analysis and calculated adjusted odds ratios (ORs).\u0000 \u0000 \u0000 \u0000 \u0000 We included 2004 patients with a stroke code, of whom 149 had an ICH, 153 had an aLVO stroke, 687 had a non‐aLVO stroke, 262 had a transient ischemic attack, and 753 had a stroke mimic. Patients with ICH and aLVO stroke more often had a positive RACE score than other patients with suspected stroke (46.2% and 58.0%, respectively, versus 6.4%;\u0000 P\u0000 <0.01). A positive RACE score had a sensitivity of 52.7%, a specificity of 93.6%, a positive predictive value of 55.4%, and a negative predictive value of 92.9% for a diagnosis of ICH or aLVO stroke. In multivariable analysis, a positive RACE score had the strongest association with ICH or aLVO stroke (adjusted OR, 10.11 [95% CI, 6.84–14.93]).\u0000 \u0000 \u0000 \u0000 \u0000 Our study shows that the RACE score can also identify patients with ICH in addition to aLVO stroke. This emphasizes the potential of the RACE score for improving prehospital triage and allocation of patients with stroke.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-08-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46836692","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The burden of acute ischemic stroke varies among racial and ethnic groups. Black adults face a higher incidence of stroke as well as higher rates of mortality. Thrombolytic therapy is under‐utilized in Black adults, and recent data show that endovascular thrombectomy is also under‐utilized for Black and Hispanic adults in the United States. Despite federal initiatives designed to promote the representation of diverse racial and ethnic groups in academic research, Black and Hispanic adults continue to be underrepresented in clinical trials conducted in the United States. Globally, the lack of standardization regarding race and ethnicity reporting makes it challenging to determine the overall diversity of trial enrollment. In this topical review, we provide an overview of racial and ethnic disparities in stroke incidence and clinical care with a focus on endovascular thrombectomy and follow this with a description of diversity reporting in endovascular thrombectomy trials. We conclude with opportunities for and barriers to increasing racial and ethnic diversity in endovascular thrombectomy trials.
{"title":"Racial and Ethnic Diversity in Endovascular Thrombectomy Trials","authors":"G. Silva, Eva A. Rocha, Amol Mehta, A. Sharrief","doi":"10.1161/svin.123.000613","DOIUrl":"https://doi.org/10.1161/svin.123.000613","url":null,"abstract":"The burden of acute ischemic stroke varies among racial and ethnic groups. Black adults face a higher incidence of stroke as well as higher rates of mortality. Thrombolytic therapy is under‐utilized in Black adults, and recent data show that endovascular thrombectomy is also under‐utilized for Black and Hispanic adults in the United States. Despite federal initiatives designed to promote the representation of diverse racial and ethnic groups in academic research, Black and Hispanic adults continue to be underrepresented in clinical trials conducted in the United States. Globally, the lack of standardization regarding race and ethnicity reporting makes it challenging to determine the overall diversity of trial enrollment. In this topical review, we provide an overview of racial and ethnic disparities in stroke incidence and clinical care with a focus on endovascular thrombectomy and follow this with a description of diversity reporting in endovascular thrombectomy trials. We conclude with opportunities for and barriers to increasing racial and ethnic diversity in endovascular thrombectomy trials.","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47101410","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
N. M. Beckonert, F. Bode, F. Dorn, S. Stösser, Julius N Meissner, J. Nordsiek, C. Kindler, Taraneh Ebrahimi, Christoph Riegler, C. Nolte, G. Petzold, Johannes M. Weller
COVID‐19 is associated with an increased stroke risk. Moreover, outcome at discharge was worse in patients with large‐vessel occlusion stroke with concomitant COVID‐19 receiving endovascular treatment (ET). We aimed to investigate the impact of concomitant COVID‐19 on later functional outcome in patients with large‐vessel occlusion stroke treated with ET. We analyzed patients from the GSR‐ET (German Stroke Registry–Endovascular Treatment), an observational multicenter registry of patients with large‐vessel occlusion stroke receiving ET. Baseline characteristics, procedural parameters, discharge parameters, and functional outcome at 90 days were compared between patients with concomitant COVID‐19 and propensity score–matched controls (ratio, 1:4; matched for age, sex, prestroke modified Rankin Scale score, and stroke severity), and multivariable ordinal regression analysis was performed. Among 4010 patients receiving ET between February 2020 and December 2021, 72 (1.8%) had concomitant COVID‐19. Compared with 224 matched patients without COVID‐19, they (n=56) were more severely affected, with a higher median National Institutes of Health Stroke Scale (NIHSS) score after 24 hours (NIHSS score, 14.5 [interquartile range {IQR}, 9–22] versus 12 [IQR, 6–18.75]; P =0.015), and NIHSS score and modified Rankin Scale score at discharge (NIHSS score, 12 [IQR, 6.75‐16.75] versus 6 [IQR, 2–13]; P =0.001; and modified Rankin Scale score, 5 [IQR, 4–5] versus 4 [IQR, 2–5]; P =0.023), but functional outcome at 90‐day follow‐up was similar (modified Rankin Scale score, 4 [IQR, 4–6] versus 4 [IQR, 2–6]; P =0.34). After adjustment for prespecified confounders, COVID‐19 was associated with worse functional outcome at discharge (common odds ratio [OR], 0.40 [95% CI, 0.19–0.80]; P =0.011), but not at 90‐day follow‐up (common OR, 0.72 [95% CI, 0.32–1.60]; P =0.43). COVID‐19 affected short‐term, but not 90‐day, functional outcome in patients with large‐vessel occlusion stroke treated with ET. Hence, ET should not be withheld in patients with concomitant COVID‐19.
{"title":"COVID‐19 Affects Short‐Term, But Not 90‐Day, Outcome in Patients With Stroke Treated With Mechanical Thrombectomy","authors":"N. M. Beckonert, F. Bode, F. Dorn, S. Stösser, Julius N Meissner, J. Nordsiek, C. Kindler, Taraneh Ebrahimi, Christoph Riegler, C. Nolte, G. Petzold, Johannes M. Weller","doi":"10.1161/svin.123.000915","DOIUrl":"https://doi.org/10.1161/svin.123.000915","url":null,"abstract":"\u0000 \u0000 COVID‐19 is associated with an increased stroke risk. Moreover, outcome at discharge was worse in patients with large‐vessel occlusion stroke with concomitant COVID‐19 receiving endovascular treatment (ET). We aimed to investigate the impact of concomitant COVID‐19 on later functional outcome in patients with large‐vessel occlusion stroke treated with ET.\u0000 \u0000 \u0000 \u0000 We analyzed patients from the GSR‐ET (German Stroke Registry–Endovascular Treatment), an observational multicenter registry of patients with large‐vessel occlusion stroke receiving ET. Baseline characteristics, procedural parameters, discharge parameters, and functional outcome at 90 days were compared between patients with concomitant COVID‐19 and propensity score–matched controls (ratio, 1:4; matched for age, sex, prestroke modified Rankin Scale score, and stroke severity), and multivariable ordinal regression analysis was performed.\u0000 \u0000 \u0000 \u0000 \u0000 Among 4010 patients receiving ET between February 2020 and December 2021, 72 (1.8%) had concomitant COVID‐19. Compared with 224 matched patients without COVID‐19, they (n=56) were more severely affected, with a higher median National Institutes of Health Stroke Scale (NIHSS) score after 24 hours (NIHSS score, 14.5 [interquartile range {IQR}, 9–22] versus 12 [IQR, 6–18.75];\u0000 P\u0000 =0.015), and NIHSS score and modified Rankin Scale score at discharge (NIHSS score, 12 [IQR, 6.75‐16.75] versus 6 [IQR, 2–13];\u0000 P\u0000 =0.001; and modified Rankin Scale score, 5 [IQR, 4–5] versus 4 [IQR, 2–5];\u0000 P\u0000 =0.023), but functional outcome at 90‐day follow‐up was similar (modified Rankin Scale score, 4 [IQR, 4–6] versus 4 [IQR, 2–6];\u0000 P\u0000 =0.34). After adjustment for prespecified confounders, COVID‐19 was associated with worse functional outcome at discharge (common odds ratio [OR], 0.40 [95% CI, 0.19–0.80];\u0000 P\u0000 =0.011), but not at 90‐day follow‐up (common OR, 0.72 [95% CI, 0.32–1.60];\u0000 P\u0000 =0.43).\u0000 \u0000 \u0000 \u0000 \u0000 COVID‐19 affected short‐term, but not 90‐day, functional outcome in patients with large‐vessel occlusion stroke treated with ET. Hence, ET should not be withheld in patients with concomitant COVID‐19.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46348342","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Siegler, Karan Patel, Kamil Taneja, Matthew B. Obusan, M. Koneru, S. Yaghi, F. Al‐Mufti, T. Kass-Hout, Thanh N. Nguyen
In 2019 and 2020, 2 randomized trials of basilar artery occlusion (BAO) thrombectomy reported no improvement in functional outcomes with thrombectomy, despite observational evidence and weak guidelines recommending thrombectomy. The objective of this study was to assess whether neutral clinical trials may have influenced BAO thrombectomy practice. The National Inpatient Sample (2018–2020) was queried for US patients with BAO, and comparisons were made between patients admitted in 2020 versus 2018 to 2019 for the primary outcome of thrombectomy. Unadjusted and adjusted multivariable regression was used, accounting for demographic and clinical covariates, with propensity‐score matching to balance clinical and hospital‐level characteristics between years. Of the 14 945 patients with BAO, 2345 (15.6%) underwent thrombectomy, with no differences in the unadjusted rate of thrombectomy between 2020 and 2018 to 2019 (14.9% versus 16.1%; P =0.41). Following multivariable adjustment, BAO thrombectomy was independently associated with a private insurance beneficiary (odds ratio [OR] 1.46, 95% CI 1.16–1.85) as compared with Medicare beneficiary; having a National Institutes of Health Stroke Scale 10–19 (OR 1.89, 95% CI 1.39–2.50) or >19 (OR 1.67, 95% CI 1.25–2.26) versus <10; but not with year of admission (OR 0.78, 95% CI 0.60–1.01; P =0.06). These relationships were preserved in the propensity‐score matching cohort, and admission year lacked association with thrombectomy for BAO (OR 0.98, 95% CI 0.73–1.33; P =0.92). Following publication of neutral BAO randomized clinical trials in late 2019 and 2020, there was no significant change in thrombectomy rate among US patients with BAO. The latest trials support thrombectomy for select patients with moderate‐to‐severe BAO symptoms, and this appears consistent with the practice of US clinicians before these trials.
{"title":"Thrombectomy Use in the United States for Basilar Artery Occlusion in the Era of Neutral Clinical Trials: 2018 to 2020 Analysis of the National Inpatient Sample","authors":"J. Siegler, Karan Patel, Kamil Taneja, Matthew B. Obusan, M. Koneru, S. Yaghi, F. Al‐Mufti, T. Kass-Hout, Thanh N. Nguyen","doi":"10.1161/svin.123.000945","DOIUrl":"https://doi.org/10.1161/svin.123.000945","url":null,"abstract":"\u0000 \u0000 In 2019 and 2020, 2 randomized trials of basilar artery occlusion (BAO) thrombectomy reported no improvement in functional outcomes with thrombectomy, despite observational evidence and weak guidelines recommending thrombectomy. The objective of this study was to assess whether neutral clinical trials may have influenced BAO thrombectomy practice.\u0000 \u0000 \u0000 \u0000 The National Inpatient Sample (2018–2020) was queried for US patients with BAO, and comparisons were made between patients admitted in 2020 versus 2018 to 2019 for the primary outcome of thrombectomy. Unadjusted and adjusted multivariable regression was used, accounting for demographic and clinical covariates, with propensity‐score matching to balance clinical and hospital‐level characteristics between years.\u0000 \u0000 \u0000 \u0000 \u0000 Of the 14 945 patients with BAO, 2345 (15.6%) underwent thrombectomy, with no differences in the unadjusted rate of thrombectomy between 2020 and 2018 to 2019 (14.9% versus 16.1%;\u0000 P\u0000 =0.41). Following multivariable adjustment, BAO thrombectomy was independently associated with a private insurance beneficiary (odds ratio [OR] 1.46, 95% CI 1.16–1.85) as compared with Medicare beneficiary; having a National Institutes of Health Stroke Scale 10–19 (OR 1.89, 95% CI 1.39–2.50) or >19 (OR 1.67, 95% CI 1.25–2.26) versus <10; but not with year of admission (OR 0.78, 95% CI 0.60–1.01;\u0000 P\u0000 =0.06). These relationships were preserved in the propensity‐score matching cohort, and admission year lacked association with thrombectomy for BAO (OR 0.98, 95% CI 0.73–1.33;\u0000 P\u0000 =0.92).\u0000 \u0000 \u0000 \u0000 \u0000 Following publication of neutral BAO randomized clinical trials in late 2019 and 2020, there was no significant change in thrombectomy rate among US patients with BAO. The latest trials support thrombectomy for select patients with moderate‐to‐severe BAO symptoms, and this appears consistent with the practice of US clinicians before these trials.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45080921","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Qianqian Kong, Zi Wang, Jing Zhao, Yi Zhang, Xirui Zhou, Lingshan Wu, Zhi-yuan Yu, Hao Huang, Xiang Luo
It remains unclear whether neuroimaging markers of cerebral small‐vessel disease (CSVD) affect the outcomes of patients with acute ischemic stroke receiving endovascular treatment (EVT). The aim of this systematic review and meta‐analysis was to evaluate the association between CSVD neuroimaging markers and outcomes in patients with acute ischemic stroke undergoing EVT. We conducted a systematic search of PubMed and EMBASE databases up to July 2022 using keywords or Medical Subject Heading terms (“cerebral small‐vessel diseases,” “leukoaraiosis,” “microbleed,” “enlarged perivascular space,” “recent small subcortical infarct,” “atrophy,” “lacune,” and “thrombectomy”). The assessed clinical outcomes were a good functional outcome, 90‐day mortality, symptomatic intracranial hemorrhage, and early neurologic improvement after EVT. Overall, 30 studies on patients with acute ischemic stroke undergoing EVT were included. Patients with absent or mild white matter hyperintensities had higher good functional outcomes (odds ratio [OR], 2.94 [95% CI, 2.44–3.53]; P <0.001) and lower mortality rate (OR, 0.42 [95% CI, 0.11–1.59]; P <0.001), whereas the presence of cerebral microbleeds increased only the risk of 90‐day mortality (OR, 0.60 [95% CI, 0.44–0.83]; P =0.002). Moreover, patients with moderate/severe CSVD burden had worse functional outcomes than those with none/mild CSVD burden (OR, 2.94 [95% CI, 2.44–3.53]; P <0.001), but neither mortality nor symptomatic intracranial hemorrhage was significantly different between the 2 groups. The existence of CSVD affected the outcomes of patients with acute ischemic stroke receiving EVT. Future multicenter prospective cohort studies with little heterogeneity should be prioritized to confirm our results.
{"title":"Cerebral Small Vessel Disease and Outcomes in Patients With Acute Ischemic Stroke Receiving Endovascular Treatment: A Systematic Review and Meta‐Analysis","authors":"Qianqian Kong, Zi Wang, Jing Zhao, Yi Zhang, Xirui Zhou, Lingshan Wu, Zhi-yuan Yu, Hao Huang, Xiang Luo","doi":"10.1161/svin.123.000866","DOIUrl":"https://doi.org/10.1161/svin.123.000866","url":null,"abstract":"\u0000 \u0000 It remains unclear whether neuroimaging markers of cerebral small‐vessel disease (CSVD) affect the outcomes of patients with acute ischemic stroke receiving endovascular treatment (EVT). The aim of this systematic review and meta‐analysis was to evaluate the association between CSVD neuroimaging markers and outcomes in patients with acute ischemic stroke undergoing EVT.\u0000 \u0000 \u0000 \u0000 We conducted a systematic search of PubMed and EMBASE databases up to July 2022 using keywords or Medical Subject Heading terms (“cerebral small‐vessel diseases,” “leukoaraiosis,” “microbleed,” “enlarged perivascular space,” “recent small subcortical infarct,” “atrophy,” “lacune,” and “thrombectomy”). The assessed clinical outcomes were a good functional outcome, 90‐day mortality, symptomatic intracranial hemorrhage, and early neurologic improvement after EVT.\u0000 \u0000 \u0000 \u0000 \u0000 Overall, 30 studies on patients with acute ischemic stroke undergoing EVT were included. Patients with absent or mild white matter hyperintensities had higher good functional outcomes (odds ratio [OR], 2.94 [95% CI, 2.44–3.53];\u0000 P\u0000 <0.001) and lower mortality rate (OR, 0.42 [95% CI, 0.11–1.59];\u0000 P\u0000 <0.001), whereas the presence of cerebral microbleeds increased only the risk of 90‐day mortality (OR, 0.60 [95% CI, 0.44–0.83];\u0000 P\u0000 =0.002). Moreover, patients with moderate/severe CSVD burden had worse functional outcomes than those with none/mild CSVD burden (OR, 2.94 [95% CI, 2.44–3.53];\u0000 P\u0000 <0.001), but neither mortality nor symptomatic intracranial hemorrhage was significantly different between the 2 groups.\u0000 \u0000 \u0000 \u0000 \u0000 The existence of CSVD affected the outcomes of patients with acute ischemic stroke receiving EVT. Future multicenter prospective cohort studies with little heterogeneity should be prioritized to confirm our results.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45756076","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Daniel A. Paydarfar, J. Holodinsky, M. Mazya, M. Hill, B. Menon, M. Jayaraman, N. Kamal
American Heart Association guidelines specify infarct core volume as 1 determinant of eligibility for endovascular thrombectomy. Therefore, it is important to understand how time‐dependent infarct core growth translates to a patient's declining probability of thrombectomy eligibility. Modeling the probability that a patient with suspected large‐vessel occlusion would qualify for thrombectomy on the basis of their expected time from stroke onset to treatment can help inform the optimal prehospital emergency transport protocols, maximizing the likelihood of an excellent patient outcome. We extended a published physiological model of infarct core growth to derive a decay curve of thrombectomy eligibility (based on a given infarct core volume threshold) as a function of time from stroke onset. We then adapted an existing model of the time‐dependent probability of an excellent outcome to incorporate this decay curve. Using the adapted model, we determined the optimal prehospital emergency transport protocols in Alberta, Canada, and compared these with the protocols that assumed all patients were thrombectomy eligible. The probability of qualifying for thrombectomy decays exponentially as time elapses from stroke onset. We found that the area where mothership is the optimal transport protocol increased by 18.6% after incorporating our decay curve of thrombectomy eligibility into the underlying optimization model. The benefit of mothership versus drip‐and‐ship also increased in the areas where mothership was favored, and in areas where drip‐and‐ship was favored, the benefit of drip‐and‐ship weakened. We also performed a number of sensitivity analyses to observe how these results change on the basis of our assumptions for model parameters. This methodology provides a novel, physiology‐based approach to derive a thrombectomy eligibility curve. These models are necessary to better optimize prehospital transport decisions and consequently improve outcomes of patients with suspected large‐vessel occlusion.
{"title":"Modeling the Decay in Probability of Receiving Endovascular Thrombectomy on the Basis of Time From Stroke Onset","authors":"Daniel A. Paydarfar, J. Holodinsky, M. Mazya, M. Hill, B. Menon, M. Jayaraman, N. Kamal","doi":"10.1161/svin.123.000932","DOIUrl":"https://doi.org/10.1161/svin.123.000932","url":null,"abstract":"\u0000 \u0000 American Heart Association guidelines specify infarct core volume as 1 determinant of eligibility for endovascular thrombectomy. Therefore, it is important to understand how time‐dependent infarct core growth translates to a patient's declining probability of thrombectomy eligibility. Modeling the probability that a patient with suspected large‐vessel occlusion would qualify for thrombectomy on the basis of their expected time from stroke onset to treatment can help inform the optimal prehospital emergency transport protocols, maximizing the likelihood of an excellent patient outcome.\u0000 \u0000 \u0000 \u0000 We extended a published physiological model of infarct core growth to derive a decay curve of thrombectomy eligibility (based on a given infarct core volume threshold) as a function of time from stroke onset. We then adapted an existing model of the time‐dependent probability of an excellent outcome to incorporate this decay curve. Using the adapted model, we determined the optimal prehospital emergency transport protocols in Alberta, Canada, and compared these with the protocols that assumed all patients were thrombectomy eligible.\u0000 \u0000 \u0000 \u0000 The probability of qualifying for thrombectomy decays exponentially as time elapses from stroke onset. We found that the area where mothership is the optimal transport protocol increased by 18.6% after incorporating our decay curve of thrombectomy eligibility into the underlying optimization model. The benefit of mothership versus drip‐and‐ship also increased in the areas where mothership was favored, and in areas where drip‐and‐ship was favored, the benefit of drip‐and‐ship weakened. We also performed a number of sensitivity analyses to observe how these results change on the basis of our assumptions for model parameters.\u0000 \u0000 \u0000 \u0000 This methodology provides a novel, physiology‐based approach to derive a thrombectomy eligibility curve. These models are necessary to better optimize prehospital transport decisions and consequently improve outcomes of patients with suspected large‐vessel occlusion.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-07-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43582232","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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