ObjectiveTo test the hypothesis that markers of coagulation and hemostatic activation (MOCHA) help identify causes of cryptogenic stroke, we obtained serum measurements on 132 patients and followed them up to identify causes of stroke.MethodsConsecutive patients with cryptogenic stroke who met embolic stroke of undetermined source (ESUS) criteria from January 1, 2017, to October 31, 2018, underwent outpatient cardiac monitoring and the MOCHA profile (serum D-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, and fibrin monomer) obtained ≥2 weeks after the index stroke; abnormal MOCHA profile was defined as ≥2 elevated markers. Prespecified endpoints monitored during routine clinical visits included new atrial fibrillation (AF), malignancy, venous thromboembolism (VTE), or other defined hypercoagulable states (HS).ResultsOverall, 132 patients with ESUS (mean age 64 ± 15 years, 61% female, 51% nonwhite) met study criteria. During a median follow-up of 10 (interquartile range 7–14) months, AF, malignancy, VTE, or HS was identified in 31 (23%) patients; the 53 (40%) patients with ESUS with abnormal MOCHA were significantly more likely than patients with normal levels to have subsequent new diagnoses of malignancy (21% vs 0%, p < 0.001), VTE (9% vs 0%, p = 0.009), or HS (11% vs 0%, p = 0.004) but not AF (8% vs 9%, p = 0.79). The combination of 4 normal MOCHA and normal left atrial size (n = 30) had 100% sensitivity for ruling out the prespecified endpoints.ConclusionThe MOCHA profile identified patients with cryptogenic stroke more likely to have new malignancy, VTE, or HS during short-term follow-up and may be useful in direct evaluation for underlying causes of cryptogenic stroke.
Background There is limited data on the markers of coagulation and hemostatic activation (MOCHA) profile in Coronavirus disease 2019 (COVID-19) and its ability to identify COVID-19 patients at risk for thrombotic events and other complications. Methods Hospitalized patients with confirmed SARS-COV-2 from four Atlanta hospitals were included in this observational cohort study and underwent admission testing of MOCHA parameters (plasma d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer). Clinical outcomes included deep vein thrombosis, pulmonary embolism, myocardial infarction, ischemic stroke, access line thrombosis, ICU admission, intubation and mortality. Main results Of 276 patients (mean age 59 ± 6.4 years, 47% female, 62% African American), 45 (16%) had a thrombotic endpoint. Each MOCHA parameter was independently associated with a thrombotic event (p<0.05) and ≥ 2 abnormalities was associated with thrombotic endpoints (OR 3.3, 95% CI 1.2–8.8) as were admission D-dimer ≥ 2000 ng/mL (OR 3.1, 95% CI 1.5–6.6) and ≥ 3000 ng/mL (OR 3.6, 95% CI 1.6–7.9). However, only ≥ 2 MOCHA abnormalities were associated with ICU admission (OR 3.0, 95% CI 1.7–5.2) and intubation (OR 3.2, 95% CI 1.6–6.4). MOCHA and D-dimer cutoffs were not associated with mortality. MOCHA with <2 abnormalities (26% of the cohort) had 89% sensitivity and 93% negative predictive value for a thrombotic endpoint. Conclusions An admission MOCHA profile is useful to risk-stratify COVID-19 patients for thrombotic complications and more effective than isolated d-dimer for predicting risk of ICU admission and intubation.
BACKGROUND There are limited data on outcomes of extracranial-intracranial (EC-IC) bypass in patients with recurrent hemispheric syndromes due to atherosclerotic internal carotid artery occlusion (AICAO). OBJECTIVE To compare clinical outcomes and efficacy of EC-IC bypass surgery in patients with and without recurrent hemispheric syndromes associated with AICAO in the Carotid Occlusion Surgery Study (COSS). METHODS In patients enrolled in the COSS trial, we compared baseline characteristics and clinical outcomes for participants with (rHEMI+) and without recurrent hemispheric ischemia (rHEMI−) prior to randomization into surgical vs medical groups. The primary outcome was all stroke and death from randomization through 30 d and ipsilateral ischemic stroke within 2 yr. RESULTS Of 195 randomized participants, 100 were rHEMI+ (50 in each group). Baseline characteristics between rHEMI+ and rHEMI− participants were similar except rHEMI+ were more likely to have had previous stroke prior to randomization (61% vs 20%, P < .01) and to have TIA as the entry event (59% vs 21%, P < .01). All primary endpoints were ipsilateral ischemic strokes. There were no significant differences in occurrence of the primary endpoint between nonsurgical and surgical participants in rHEMI+ (26.3% vs 22.4%, P = .660) and rHEMI− (18.9% vs 19.5%, P = .943). For nonsurgical participants, there was no significant difference in the primary endpoint for rHEMI+ vs rHEMI− patients (P = .410) CONCLUSION Patients with recurrent hemispheric stroke syndromes enrolled in the COSS trial did not show benefit from EC-IC bypass compared to medical treatment. Early aggressive risk factor measures should be prioritized to reduce recurrent strokes in these patients.
Background Young patients experience acute ischemic stroke (AIS) at much lower rates than their older counterparts. We performed a systematic review and meta-analysis to assess the question regarding outcomes and clinical characteristics of young stroke patients who underwent mechanical thrombectomy for AIS. Methods Following PRISMA guidelines, a systematic review of the literature was conducted using the databases PubMed, MEDLINE, and Embase. The primary outcome of interest was 90-day modified Rankin Scale (mRS) 0–2. Secondary outcome variables included rate of successful reperfusion (TICI 2b/3), symptomatic intracerebral hemorrhage (sICH), and mortality. Using R software version 4.1.2, we calculated pooled event rates and their corresponding 95% confidence intervals (CI) for all outcomes. Results Our analysis included eight studies with a total of 1903 patients. Definitions of young patients included age ranges of 18–49/50 years, 18–54/55 years, and 18–64/65 years. Functional independence was achieved in 62.0% of the patients, with an overall mortality of 9.0%. Moreover, successful reperfusion was achieved in 82.0% of the patients with sICH rates of 5.7%. There was significant heterogeneity among different analyses, which could not be attributed to the differences of the definition of young patients. Conclusions Following mechanical thrombectomy for AIS, patients aged 18–65 years achieved relatively high rates of functional independence and successful reperfusion and low rates of mortality and sICH. Clinical Perspective In this systematic review and meta-analysis of eight studies, we examined outcomes in young stroke patients, aged 18–65 years old, following mechanical thrombectomy for acute ischemic stroke. We found that young patients achieved high rates of functional independence, high rates of successful reperfusion, and low rates of mortality and symptomatic intracerebral hemorrhage. While there have been several papers examining outcomes following mechanical thrombectomy for acute ischemic stroke in young patients, the results of these studies have yet to be pooled together in a meta-analysis. Our results indicate that young patients have good outcomes following mechanical thrombectomy. Further studies that examine these outcomes are warranted so that a higher-powered analysis can be performed to better informed clinicians regarding outcomes in this patient age-group cohort.
Background Delayed neurological improvement (DNI) is a phenomenon that involves patient improvement in the absence of early neurological change following treatment for acute ischemic stroke. The patient characteristics associated with this condition are largely unexplored. Methods Following the PRISMA guidelines, a systematic review of the English language literature was conducted using PubMed, Embase, Web of science, and Scopus. We calculated pooled odds ratios (ORs), mean differences (MDs), and their corresponding 95% confidence intervals (CIs) to test the association between patient characteristics and achievement of DNI. Results Seven studies, with 3266 patients, were included in our analysis. All studies reported a different definition of DNI, with five studies focusing on rates of good functional outcome at 90 days post-treatment in the absence of early neurological improvement. Use of intravenous thrombolytics was associated with increased rates of DNI (OR 1.96, 95% CI 1.28 to 3.00; p = 0.002). Atrial fibrillation was associated with decreased rates of DNI (OR 0.69, 95% CI 0.57 to 0.82; p < 0.001), as was hypertension (OR 0.66, 95% CI 0.53 to 0.83, p < 0.001), and diabetes mellitus (OR 0.71, 95% CI 0.56 to 0.90; p = 0.005). On average, patients who achieved DNI were 6.30 years younger than their non-DNI counterparts ( MD −6.30, 95% CI −9.19 to −3.41; p < 0.001). There were modest associations between male sex and DNI (OR 1.36, 95% CI 1.01 to 1.74, p = 0.042), and smoking and DNI (OR 1.28, 95% CI 1.03 to 1.59, p = 0.027). Conclusions DNI is a phenomenon that is not presently well understood. Lack of uniformity among definitions of DNI hinders efforts to explore DNI and the factors associated with its occurrence. Future studies should work to establish a consensus definition of DNI to determine its causes and significance more accurately.
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