What is the outcome of thrombolysis for stroke of unknown onset time?

Intravenous thrombolysis in unknown-onset stroke: results from the safe implementation of treatment in Stroke-International Stroke Thrombolysis Registry.

Dorado L, Ahmed N, Thomalla G, et al.

Stroke 2017; 48:720-725.

Abstract

Background:

Stroke patients with unknown onset (UKO) are excluded from thrombolytic therapy. We aim to study the safety and efficacy of intravenous alteplase in ischemic stroke patients with UKO of symptoms compared with those treated within 4.5 hours in a large cohort.

Methods:

Data were analyzed from 47 237 patients with acute ischemic stroke receiving intravenous tissue-type plasminogen activator in hospitals participating in the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Registry between 2010 and 2014. Two groups were defined: (1) patients with UKO (n=502) and (2) patients treated within 4.5 hours of stroke onset (n=44 875). Outcome measures were symptomatic intracerebral hemorrhage per Safe Implementation of Treatment in Stroke on the 22 to 36 hours post-treatment neuroimaging and mortality and functional outcome assessed by the modified Rankin Scale at 3 months.

Results:

Patients in UKO group were significantly older, had more severe stroke at baseline, and longer door-to-needle times than patients in the ≤4.5 hours group. Logistic regression showed similar risk of symptomatic intracerebral hemorrhage (adjusted odds ratio, 1.09; 95% confidence interval, 0.44–2.67) and no significant differences in functional independency (modified Rankin Scale score of 0–2; adjusted odds ratio, 0.79; 95% confidence interval, 0.56–1.10), but higher mortality (adjusted odds ratio, 1.58; 95% confidence interval, 1.04–2.41) in the UKO group compared with the ≤4.5 hours group. Patients treated within 4.5 hours showed reduced disability over the entire range of modified Rankin Scale compared with the UKO group (common adjusted odds ratio, 1.29; 95% confidence interval, 1.01–1.65).

Conclusions:

Our data suggest no excess risk of symptomatic intracerebral hemorrhage but increased mortality and reduced favorable outcome in patients with unknown onset stroke compared with patients treated within the approved time window.

This reference is now included in the neurochecklist:

 

Abstract link

By Blausen Medical Communications, Inc. – Donated via OTRS, see ticket for details, CC BY 3.0, Link
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Why is the diagnosis of cervical artery dissection difficult in older people?

CADISP-Plus Study Group. Cervical artery dissection in patients ≥60 years: often painless, few mechanical triggers

Traenka C, Dougoud D, Simonetti BG, et al;

Neurology 2017; 88:1313-1320.

Abstract

OBJECTIVE:

In a cohort of patients diagnosed with cervical artery dissection (CeAD), to determine the proportion of patients aged ≥60 years and compare the frequency of characteristics (presenting symptoms, risk factors, and outcome) in patients aged <60 vs ≥60 years.

METHODS:

We combined data from 3 large cohorts of consecutive patients diagnosed with CeAD (i.e., Cervical Artery Dissection and Ischemic Stroke Patients-Plus consortium). We dichotomized cases into 2 groups, age ≥60 and <60 years, and compared clinical characteristics, risk factors, vascular features, and 3-month outcome between the groups. First, we performed a combined analysis of pooled individual patient data. Secondary analyses were done within each cohort and across cohorts. Crude and adjusted odds ratios (OR [95% confidence interval]) were calculated.

RESULTS:

Among 2,391 patients diagnosed with CeAD, we identified 177 patients (7.4%) aged ≥60 years. In this age group, cervical pain (ORadjusted 0.47 [0.33-0.66]), headache (ORadjusted 0.58 [0.42-0.79]), mechanical trigger events (ORadjusted 0.53 [0.36-0.77]), and migraine (ORadjusted 0.58 [0.39-0.85]) were less frequent than in younger patients. In turn, hypercholesterolemia (ORadjusted 1.52 [1.1-2.10]) and hypertension (ORadjusted 3.08 [2.25-4.22]) were more frequent in older patients. Key differences between age groups were confirmed in secondary analyses. In multivariable, adjusted analyses, favorable outcome (i.e., modified Rankin Scale score 0-2) was less frequent in the older age group (ORadjusted 0.45 [0.25, 0.83]).

CONCLUSION:

In our study population of patients diagnosed with CeAD, 1 in 14 was aged ≥60 years. In these patients, pain and mechanical triggers might be missing, rendering the diagnosis more challenging and increasing the risk of missed cervical artery dissection diagnosis in older patients.

This reference is cited in the neurochecklist:

Cervical artery dissection (CEAD): clinical features

Abstract link

By Henry Vandyke CarterHenry Gray (1918) Anatomy of the Human Body (See “Book” section below)Bartleby.com: Gray’s Anatomy, Plate 513, Public Domain, Link

What are the downsides of mechanical thrombectomy for stroke?

Thrombectomy for ischemic stroke: meta-analyses of recurrent strokes, vasospasms, and subarachnoid hemorrhages.

Emprechtinger R, Piso B, Ringleb PA.

J Neurol 2017; 264:432-436.

Abstract

Background:

Mechanical thrombectomy with stent retrievers is an effective treatment for patients with ischemic stroke. Results of recent meta-analyses report that the treatment is safe. However, the endpoints recurrent stroke, vasospasms, and subarachnoid hemorrhage have not been evaluated sufficiently. Hence, we extracted data on these outcomes from the five recent thrombectomy trials (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND IA published in 2015). Subsequently, we conducted meta-analyses for each outcome.

Methods:

We report the results of the fixed, as well as the random effects model. Three studies reported data on recurrent strokes. While the results did not reach statistical significance in the random effects model (despite a three times elevated risk), the fixed effects model revealed a significantly higher rate of recurrent strokes after thrombectomy.

Results:

Four studies reported data on subarachnoid hemorrhage. The higher pooled rates in the intervention groups were statistically significant in both, the fixed and the random effects model. One study reported on vasospasms. We recorded 14 events in the intervention group and none in the control group.

Conclusions:

The efficacy of mechanical thrombectomy is not questioned, yet our results indicate an increased risk for recurrent strokes, subarachnoid hemorrhage, and vasospasms post-thrombectmy. Therefore, we strongly recommend a thoroughly surveillance, concerning these adverse events in future clinical trials and routine registries.

This reference is cited in the neurochecklist:

Ischaemic stroke: thrombectomy

Abstract link

By Neilbarman at English Wikipedia, CC BY-SA 3.0, Link

How does alcohol affect the risk of intracerebral haemorrhage?

The following abstract is based on the Neurochecklist:

Alcohol use and risk of intracerebral hemorrhage

Chen CJ, Brown WM, Moomaw CJ, et al; ERICH Investigators.

Neurology 2017; 88:2043-2051.

Abstract

OBJECTIVE:

To analyze the dose-risk relationship for alcohol consumption and intracerebral hemorrhage (ICH) in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study.

METHODS:

ERICH is a multicenter, prospective, case-control study, designed to recruit 1,000 non-Hispanic white patients, 1,000 non-Hispanic black patients, and 1,000 Hispanic patients with ICH. Cases were matched 1:1 to ICH-free controls by age, sex, race/ethnicity, and geographic area. Comprehensive interviews included questions regarding alcohol consumption. Patterns of alcohol consumption were categorized as none, rare (<1 drink per month), moderate (≥1 drink per month and ≤2 drinks per day), intermediate (>2 drinks per day and <5 drinks per day), and heavy (≥5 drinks per day). ICH risk was calculated using the no-alcohol use category as the reference group.

RESULTS:

Multivariable analyses demonstrated an ordinal trend for alcohol consumption: rare (odds ratio [OR] 0.57, p < 0.0001), moderate (OR 0.65, p < 0.0001), intermediate (OR 0.82, p = 0.2666), and heavy alcohol consumption (OR 1.77, p = 0.0003). Subgroup analyses demonstrated an association of rare and moderate alcohol consumption with decreased risk of both lobar and nonlobar ICH. Heavy alcoholconsumption demonstrated a strong association with increased nonlobar ICH risk (OR 2.04, p = 0.0003). Heavy alcohol consumption was associated with significant increase in nonlobar ICH risk in black (OR 2.34, p = 0.0140) and Hispanic participants (OR 12.32, p < 0.0001). A similar association was not found in white participants.

CONCLUSIONS:

This study demonstrated potential protective effects of rare and moderate alcohol consumption on ICH risk. Heavy alcoholconsumption was associated with increased intracerebral haemorrhage risk. Race/ethnicity was a significant factor in alcohol-associated ICH risk; heavy alcohol consumption in black and Hispanic participants poses significant nonlobar ICH risk.

Abstract link

By Nik Frey (niksan) – stock.xchng: http://www.sxc.hu/browse.phtml?f=view&id=207042 [dead link], CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=26539

Is stroke thrombolysis risky in people with sickle cell disease?

Coexistent sickle cell disease has no impact on the safety or outcome of lytic therapy in acute ischemic stroke: findings from get with the guidelines-stroke.

Adams RJ, Cox M, Ozark SD, et al.

Stroke 2017; 48:686-691.

Abstract

BACKGROUND:

The recommended treatment for ischemic stroke is tPA (tissue-type plasminogen activator). Although sickle cell disease (SCD) represents no known contraindication to tPA, National Heart Lung and Blood Institute of the National Institutes of Health recommended acute exchange transfusion for stroke in SCD, not tPA. Data on safety and outcomes of tPA in patients are needed to guide tPA use in SCD.

METHODS:

We matched patients from the American Heart Association and American Stroke Association Get With The Guidelines-Stroke registry with SCD to patients without SCD and compared usage, complications, and discharge outcomes after tPA. Multivariable logistic regression models using generalized estimating equations were used to assess outcomes.

RESULTS:

From 2 016 652 stroke patients admitted to Get With The Guidelines-Stroke sites in the United States, 832 SCD and 3328 non-SCD controls with no differences in admission National Institutes of Health Stroke Scale or blood pressure were identified. Neither the fraction receiving thrombolytic therapy (8.2% for SCD versus 9.4% non-SCD) nor symptomatic intracranial hemorrhage (4.9% of SCD versus 3.2% non-SCD; P=0.4502) was different. There was no difference in a prespecified set of outcome measures for those with SCD compared with controls.

CONCLUSIONS:

Coexistent sickle cell disease had no significant impact on the safety or outcome of thrombolytic therapy in acute ischemic stroke. Although the sample size is relatively small, these data suggest that adults with SCD and acute ischemic stroke should be treated with thrombolysis, if they otherwise qualify. Addition studies, however, should track the intracranial hemorrhage rate and provide information on other SCD-related care such as transfusion.

This reference is cited in the neurochecklist:

Sickle cell disease (SCD): management

Abstract link

Sickle cell disease (SCD). NIH Image Gallery on Flikr. https://www.flickr.com/photos/nihgov/24170591501

Is migraine a risk factor for peri-operative stroke?

Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study

Timm FP, Houle TT, Grabitz SD, et al.

BMJ 2017; 356:i6635.

Abstract

OBJECTIVE:

To evaluate whether patients with migraine are at increased risk of perioperative ischemic stroke and whether this may lead to an increased hospital readmission rate.

MAIN OUTCOME MEASURES:

The primary outcome was perioperative ischemic stroke occurring within 30 days after surgery in patients with and without migraine and migraine aura. The secondary outcome was hospital readmission within 30 days of surgery. Exploratory outcomes included post-discharge stroke and strata of neuroanatomical stroke location.

RESULTS:

10 179 (8.2%) patients had any migraine diagnosis, of whom 1278 (12.6%) had migraine with aura and 8901 (87.4%) had migraine without aura. 771 (0.6%) perioperative ischemic strokes occurred within 30 days of surgery. Patients with migraine were at increased risk of perioperative ischemic stroke (adjusted odds ratio 1.75, 95% confidence interval 1.39 to 2.21) compared with patients without migraine. The risk was higher in patients with migraine with aura (adjusted odds ratio 2.61, 1.59 to 4.29) than in those with migraine without aura (1.62, 1.26 to 2.09). The predicted absolute risk is 2.4 (2.1 to 2.8) perioperative ischemic strokes for every 1000 surgical patients. This increases to 4.3 (3.2 to 5.3) for every 1000 patients with any migraine diagnosis, 3.9 (2.9 to 5.0) for migraine without aura, and 6.3 (3.2 to 9.5) for migraine with aura. : Patients with migraine had a higher rate of readmission to hospital within 30 days of discharge (adjusted odds ratio 1.31, 1.22 to 1.41).

CONCLUSIONS:

Surgical patients with a history of migraine are at increased risk of perioperative ischemic stroke and have an increased 30 day hospital readmission rate. Migraine should be considered in the risk assessment for perioperative ischemic stroke.

This reference is included in the neurochecklists:

Ischaemic stroke: non-genetic risk factors

&

Migraine and stroke

 

Abstract link

By see above – Album comique de pathologie pittoresque Paris : Tardieu, 1823 The National Library of Medicine, Public Domain, Link

Should lacunar strokes be treated with thrombolysis?

The efficacy of thrombolysis in lacunar stroke-evidence from the Austrian Stroke Unit Registry

Eggers CCJ, Bocksrucker C, Seyfang L; Austrian Stroke Unit Registry Collaborators.

Eur J Neurol 2017; 24:780-787.

Abstract

BACKGROUND AND PURPOSE:

Intravenous thrombolysis (ivT) with recombinant tissue plasminogen activator is established in acute ischaemic stroke. Little is known, however, about its efficacy in different stroke subtypes.

METHODS:

A retrospective analysis of 128 733 patients from the Austrian Stroke Unit Registry was performed. Patients were classified as lacunar (LacS) or non-lacunar ischaemic stroke (nonLacS) by use of the clinical syndrome and technical findings. Outcome parameters were the short term improvement in the stroke unit [the difference of the National Institutes of Health Stroke Scale (NIHSS) score at admission and at discharge] and the modified Rankin Scale (mRS) score at 3 months. Patients were assigned to four groups according to thrombolysis and stroke subtype. To control for confounding, patients were matched for variables identified with impact outcome and for variables of general interest (NIHSS at admission, mRS before stroke and general risk factors).

RESULTS:

There were four matched groups of 401 cases each. In LacS median short term improvement was 3 [interquartile range (IQR) 2-5] NIHSS points in the thrombolysed patients and 2 (IQR 1-4) in the non-thrombolysed patients (P < 0.001). In the nonLacS groups median short term improvement was 3 (IQR 1-5) in the thrombolysed and 2 (IQR 0-4) in the non-thrombolysed patients (P < 0.001). At 3-month follow-up, ivT was significantly associated with a better functional outcome in LacS (P < 0.001) and nonLacS patients (P < 0.001). Taking magnetic resonance imaging as a requirement for stroke subtyping led to similar results.

CONCLUSIONS:

Patients with both lacunar and non-lacunar stroke benefitted from intravenous thrombolysis. The degree of improvement was similar in both groups.

This reference is included in the neurochecklist:

Thrombolysis: indications and clinical use

Abstract link

By Wikid77 – Derivative of Image:Gray516.png, narrowing labels to magnify image 16%; removed smudges near labels., Public Domain, Link

What features distinguish carotid from vertebral artery dissection?

Differential features of carotid and vertebral artery dissections. The CADISP study

Debette S, Grond-Ginsbach C, Bodenant M, et al.

Neurology 2011; 77:1174-1181.

Abstract

OBJECTIVE:

To examine whether risk factor profile, baseline features, and outcome of cervical artery dissection (CEAD) differ according to the dissection site.

METHODS:

We analyzed 982 consecutive patients with CEAD included in the Cervical Artery Dissection and Ischemic Stroke Patients observational study (n = 619 with internal carotid artery dissection [ICAD], n = 327 with vertebral artery dissection [VAD], n = 36 with ICAD and VAD).

RESULTS:

Patients with internal carotid artery dissection (ICAD) were older (p < 0.0001), more often men (p = 0.006), more frequently had a recent infection (odds ratio [OR] = 1.59 [95% confidence interval (CI) 1.09-2.31]), and tended to report less often a minor neck trauma in the previous month (OR = 0.75 [0.56-1.007]) compared to patients with VAD. Clinically, patients with ICAD more often presented with headache at admission (OR = 1.36 [1.01-1.84]) but less frequently complained of cervical pain (OR = 0.36 [0.27-0.48]) or had cerebral ischemia (OR = 0.32 [0.21-0.49]) than patients with VAD. Among patients with CEAD who sustained an ischemic stroke, the NIH Stroke Scale (NIHSS) score at admission was higher in patients with ICAD than patients with VAD (OR = 1.17 [1.12-1.22]). Aneurysmal dilatation was more common (OR = 1.80 [1.13-2.87]) and bilateral dissection less frequent (OR = 0.63 [0.42-0.95]) in patients with ICAD. Multiple concomitant dissections tended to cluster on the same artery type rather than involving both a vertebral and carotid artery. Patients with ICAD had a less favorable 3-month functional outcome (modified Rankin Scale score >2, OR = 3.99 [2.32-6.88]), but this was no longer significant after adjusting for baseline NIHSS score.

CONCLUSION:

In the largest published series of patients with CEAD, we observed significant differences between VAD and ICAD in terms of risk factors, baseline features, and functional outcome.

This reference is cited in the neurochecklist:

Abstract link

By Germain Orphanet Journal of Rare Diseases 2007 2:32 doi:10.1186/1750-1172-2-32, CC BY 2.0, Link

Do oral contraceptives increase the risk of stroke in people with migraine?

Use of combined hormonal contraceptives among women with migraines and risk of ischemic stroke

Champaloux SW, Tepper NK, Monsour M, et al.

Am J Obstet Gynecol 2017; 216:489.e1-489.e7.

Abstract

BACKGROUND:

Migraine with aura and combined hormonal contraceptives are independently associated with an increased risk of ischemic stroke. However, little is known about whether there are any joint effects of migraine and hormonal contraceptives on risk of stroke.

OBJECTIVE:

We sought to estimate the incidence of stroke in women of reproductive age and examine the association among combined hormonal contraceptive use, migraine type (with or without aura), and ischemic stroke.

STUDY DESIGN:

This study used a nationwide health care claims database and employed a nested case-control study design. Females ages 15-49 years with first-ever stroke during 2006 through 2012 were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification inpatient services diagnosis codes. Four controls were matched to each case based on age. Migraine headache with and without aura was identified using inpatient or outpatient diagnosis codes. Current combined hormonal contraceptive use was identified using the National Drug Code from the pharmacy database. Conditional logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals of ischemic stroke by migraine type and combined hormonal contraceptive use.

RESULTS:

From 2006 through 2012, there were 25,887 ischemic strokes among females ages 15-49 years, for a cumulative incidence of 11 strokes/100,000 females. Compared to those with neither migraine nor combined hormonal contraceptive use, the odds ratio of ischemic stroke was highest among those with migraine with aura using combined hormonal contraceptives (odds ratio, 6.1; 95% confidence interval, 3.1-12.1); odds ratios were also elevated for migraine with aura without combined hormonal contraceptive use (odds ratio, 2.7; 95% confidence interval, 1.9-3.7), migraine without aura and combined hormonal contraceptive use (odds ratio, 1.8; 95% confidence interval, 1.1-2.9), and migraine without aura without combined hormonal contraceptive use (odds ratio, 2.2; 95% confidence interval, 1.9-2.7).

CONCLUSION:

The joint effect of combined hormonal contraceptives and migraine with aura was associated with a 6-fold increased risk of ischemic stroke compared with neither risk factor. Use of combined hormonal contraceptives did not substantially further increase risk of ischemic stroke among women with migraine without aura. Determining migraine type is critical in assessing safety of combined hormonal contraceptives among women with migraine.

This reference is included in the neurochecklist:

Migraine risk factors

Abstract link

By BetteDavisEyes at English Wikipedia – Transferred from en.wikipedia to Commons.; transfer was stated to be made by Tanvir., Public Domain, Link

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