Stroke (Hoboken, N.J.)最新文献

Background: Recent randomized clinical trials of endovascular therapy in patients with large infarct provided new evidence in support of endovascular interventions in patients with acute ischemic stroke. The Society of Vascular and Interventional Neurology Guidelines and Practice Standards committee aims to provide up-to-date recommendations on focused relevant clinical questions. Here, we review current evidence and provide recommendations for the selection and endovascular treatment of patients with anterior circulation large vessel occlusion and large infarct.

Methods: The Society of Vascular and Interventional Neurology Guidelines and Practice Standards committee assembled a writing group and recruited interdisciplinary experts to review and evaluate the current literature. Recommendations were assigned using the Guidelines and Practice Standards Class of Recommendation/Level of Evidence algorithm and guideline format. The recommendations were developed through a consensus process involving an expert panel of vascular neurologists, neurointensivists, and neurointerventionalists. The final guideline was approved by the Guidelines and Practice Standards committee and the Society of Vascular and Interventional Neurology board of directors.

Results: Literature review yielded 6 high-quality randomized trials and 6 meta-analyses of patients with large infarct from anterior circulation large vessel occlusion treated with endovascular therapy versus medical management that have been extracted to derive the enclosed summary recommendations. We provide separate recommendations for those presenting within 6 hours of symptoms onset and those presenting in the 6-24-hour treatment window.

Conclusion: These guidelines provide focused practical recommendations based on recent evidence regarding the selection and endovascular therapy in patients with acute ischemic stroke with large infarct.

[This corrects the article DOI: 10.1161/SVIN.123.001246.].

Background: In people with suspected stroke the first assessment occurs under time pressure in the emergency department and is based solely on clinical information. Working hypotheses include mechanism and localization of the clinical deficit on imaging. To assess the performance of neurologists in such situation, we investigated the accuracy with which board-certified neurologists make the correct diagnosis based solely on clinical information.

Methods: In this prospective diagnostic accuracy study done at an emergency department of a university hospital, neurologists had to commit themselves to a diagnosis in people with suspected acute stroke. The main analysis was the accuracy with which they distinguished vascular from nonvascular causes using the discharge diagnosis as a reference. Secondary analyses included the distinction of ischemic from hemorrhagic strokes, and the accuracy with which the lesion location and site of vessel occlusion were identified. The performance of neurologists was also compared to residents and medical students.

Results: Of 800 people with suspected stroke, 567 (71%) had a vascular (508 ischemic stroke or transient ischemic attack and 59 hemorrhagic stroke) and 233 (29%) had a nonvascular disorder (72 seizures, 33 migraine auras, 12 functional neurological disorders, and 116 other diseases). Vessel occlusion was found in 227 of 410 people with ischemic stroke. Neurologists identified vascular origin with an accuracy of 0.86 (95% CI: 0.83-0.89), a sensitivity of 0.93 (0.90-0.95), and a specificity of 0.66 (0.58-0.73). The accuracy to identify ischemia compared with hemorrhage was 0.91 (0.87-0.93). Neurologists' accuracy to predict the presence of vessel occlusion was 0.66 (0.61-0.71), of exact lesion location was 42%, and of the affected blood vessel 57%.

Conclusion: In people with acute neurological deficits, the accuracy with which neurologists identify vascular origin is high and depends on neurological education. Experienced physicians should be involved early in the management of people with "code stroke."

Background: The efficacy and safety of endovascular thrombectomy (EVT) performed beyond 24 hours from the last known well remain uncertain. This study aims to investigate the potential benefits of EVT versus best medical management (BMM) beyond 24 hours.

Methods: TRACK-LVO Late (Late Triage of Patients Presenting Beyond 24 Hours With Acute Ischemic Stroke Due to Large Vessel Occlusions) is an ongoing, multicenter, prospective cohort study. A total of 410 individuals met the inclusion and exclusion criteria and were included in the cohort analyses from 2018 to 2024. The primary outcome was functional independence, defined as a modified Rankin Scale score of 0-2 at 90 days. Safety outcomes included all-cause mortality within 90 days and symptomatic intracranial hemorrhage. A propensity score analysis was conducted to adjust for baseline imbalances. The association between treatment and primary outcome/safety outcomes was assessed using logistic regression, adjusted for age, sex, National Institutes of Health Stroke Scale score, premorbid modified Rankin Scale score, occlusion sites, and time from onset to admission.

Results: Among the 410 patients, 209 were in the EVT group and 201 in the BMM group. The EVT group showed higher odds of functional independence in the propensity score-matched cohort (adjusted odds ratio, 4.13 [95% CI, 2.42-7.05]; P<0.001). No significant difference in mortality rate was observed between groups (adjusted odds ratio, 1.59 [95% CI, 0.60-4.25]; P = 0.354). However, the EVT group had an increased risk of symptomatic intracranial hemorrhage compared with the BMM group (adjusted odds ratio, 8.72 [95% CI, 1.04-73.10]; P = 0.046). These findings were consistent in sensitivity analyses using propensity score inverse probability of treatment weighting.

Conclusion: EVT performed after 24 hours from the last known well was associated with higher rates of functional independence compared with BMM and demonstrated acceptable safety. High-quality randomized trials are needed to further compare EVT and BMM beyond 24 hours from the last known well.

Background: Patients with heart failure (HF) treated with mechanical thrombectomy (MT) for acute ischemic stroke were underrepresented in clinical trials on MT. Our systematic review and meta-analysis aim to assess differences in outcomes between patients with HF and their counterparts without HF treated with MT for acute ischemic stroke.

Methods: A systematic review of the English language literature from inception up to March 7, 2024, was conducted using PubMed, Embase, Cochrane Library, and Web of Science databases. Studies focused on patients with and without HF who were treated with MT for acute ischemic stroke were included. The primary outcome of interest was the rate of modified Rankin Scale scores of 0-2 at 90 days. Secondary outcomes of interest included rates of 90-day mortality, successful reperfusion, and symptomatic intracranial hemorrhage.

Results: Of 5394 initially retrieved studies, 5 studies were included in the systematic review with a final population of 44 385 patients with ischemic stroke with and without HF treated with MT. Four studies were combined for the primary outcome and showed comparable rates of 0-2 modified Rankin Scale scores between patients with HF and patients without HF (odds ratio, 0.86 [95% CIs, 0.70-1.06]; P = 0.15). Ninety-day mortality was significantly higher in the HF group (odds ratio, 1.92 [95% CIs, 1.66-2.23]; P<0.0001) although the sample size was small (n of study = 3) and only unadjusted estimates were used. Successful reperfusion and symptomatic intracranial hemorrhage rates were similar between the groups.

Conclusion: In this systematic review and meta-analysis, patients with HF experienced worse 90-day mortality post-MT. Our data encourage further research on MT outcomes in patients with large vessel-occlusion ischemic stroke and concomitant HF.

Background: Nearly one fifth of the US population resides in rural areas. Although endovascular therapy can substantially improve clinical outcomes in patients treated with large vessel occlusion acute ischemic stroke, the penetration and outcomes of this therapy in rural US populations remain incompletely characterized.

Methods: From the nationwide Get With The Guidelines Stroke registry, incorporating select social determinants of health (SDOH) by the Institute for Health Metrics and Evaluation registry (2016-2019), we identified patients with acute ischemic stroke and transient ischemic attack who were transferred from their presenting hospitals to other hospitals with the intention of thrombectomy evaluation, for patients residing in rural and nonrural areas. The primary outcome was the likelihood of undergoing intra-arterial catheter-based therapy after transfer, adjusted for stroke severity, age, baseline ambulatory status, and select SDOH, by multivariable logistic regression.

Results: Among 24 620 patients meeting inclusion criteria, 5.1% resided in rural areas. Patients residing in rural areas transferred for endovascular therapy evaluation experienced less favorable SDOH than patients residing in nonrural areas (P<0.01, each, for education, income, homeownership, poverty, and unemployment). Patients in both groups presented with moderate/severe stroke and similar vascular risk factors. Patients residing in rural areas were 15% less likely to undergo endovascular therapy, when adjusting for stroke severity, age, baseline ambulatory status, and select SDOH (40.8% versus 49.4%; adjusted odds ratio [aOR], 0.85 [95% CI, 0.74-0.99]). Patients residing in rural areas experienced similar incidence of reported transfer delays as patients residing in non-rural areas (0.1%, each; aOR, 1.36 [95% CI, 0.56-6.84]).

Conclusion: In this nationwide cohort study, patients living in rural areas with acute ischemic stroke or transient ischemicattack who were transferred to other hospitals for endovascular therapy evaluation were less likely to undergo intra-arterial catheter-based therapy, despite similar incidence of transfer delays, and when adjusting for select SDOH commonly associated with rurality.

Background: Patent foramen ovale (PFO) contributes to a quarter of embolic strokes of undetermined source. Although the benefit of PFO closure in selected patients has been demonstrated, our system workflow still resulted in a low rate of PFO evaluation for closure. The aim of the PFO-ACCESS (Augmenting Communications for Medical Care or Closure in the Evaluation of Stroke Patients With Cardiac Shunts) program (which included implementation of the Viz.ai PFO-specific communications module) was to determine if there was any change in PFO management due to improved communication between stroke and interventional cardiology teams.

Methods: In this quality improvement project, we compared pre-PFO ACCESS (December 2022-November 2023) to post-PFO ACCESS periods (November 2023-June 2024) regarding PFO evaluations. The Viz.ai PFO module was implemented for the stroke and interventional cardiology teams without other workflow changes. Key performance indicators included referral frequency, PFO closure rates, and referral time intervals. Statistical comparisons utilized Mann-Whitney U, chi-square, Fisher's exact, and exact Poisson test where appropriate.

Results: The postimplementation period noted a 492% PFO referral increase (11 versus 38,65 [annualized]; P<0.0001). PFO closure number totals showed a 186% nonsignificant increase pre versus post (6 versus 10,17 [annualized]; P = 0.99), with PFO closure of percentage of total referred cases showing a large but nonsignificant decrease (54.55%, 26.32%; P = 0.14). Time comparisons showed a marked but nonsignificant decrease in median "referral sent to referral viewed" (10:37 hours, 1:08 hours; P = 0.73), "referral sent to referral accepted" (10:37 hours, 1:03 hours; P = 0.67) time interval, and "referral sent to closure" time interval (102 days, 97 days; P = 0.55).

Conclusion: The PFO-ACCESS program with Viz.ai PFO module use resulted in a 492% increase in PFO referrals due to enhanced communication and efficiency in managing PFO-related stroke cases. Though the increased number of referrals and closures were observed, the PFO closure percentage of total referred cases showed a marked but nonsignificant decrease indicating selective case management. The higher number of PFO closures shows that more patients are indeed appropriate for PFO closure consideration. Future efforts should focus on expanding outpatient use and increasing provider education to optimize PFO management.