Abnormal TEE findings may decisively affect the selection of appropriate therapeutic strategy in approximately 1 of 7 patients with ESUS.
Background Recent guidelines for endovascular management of emergent large vessel occlusion (ELVO) award top tier evidence to the same selective criteria in recent trials. We aimed to understand how guideline adherence would have impacted treatment numbers and outcomes in a cohort of patients from a comprehensive stroke center. Methods A retrospective observational study was conducted using consecutive emergent endovascular patients. Mechanical thrombectomy (MT) was performed with stent retrievers or large bore clot aspiration catheters. Procedural outcomes were compared between patients meeting, and those failing to meet, top tier evidence criteria.Results 126 patients receiving MT from January 2012 to June 2015 were included (age 31-89 years, National Institutes of Health Stroke Scale (NIHSS) score 2-38); 62 (49%) patients would have been excluded if top tier criteria were upheld: pretreatment NIHSS score <6 (10%), Alberta Stroke Program Early CT score <6 (6.5%), premorbid modified Rankin Scale (mRS) score ≥2 (27%), M2 occlusion (10%), posterior circulation (32%), symptom to groin puncture >360 min (58%). 26 (42%) subjects had more than one top tier exclusion. Symptomatic intracerebral hemorrhage (sICH) and systemic hemorrhage rates were similar between the groups. 3 month mortality was 45% in those lacking top tier evidence compared with 26% (p=0.044), and 3 month mRS score 0-2 was 33% versus 46%, respectively (NS). After adjusting for potential confounders, top tier treatment was not associated with neurological improvement during hospitalization (β −8.2; 95% CI −24.6 to −8.2; p=0.321), 3 month mortality (OR=0.38; 95% CI 0.08 to 1.41), or 3 month favorable mRS (OR=0.97; 95% CI 0.28 to 3.35). Conclusions Our study showed that with strict adherence to top tier evidence criteria, half of patients may not be considered for MT. Our data indicate no increased risk of sICH and a potentially higher mortality that is largely due to treatment of patients with basilar occlusions and those treated at an extended time window. Despite this, good functional recovery is possible, and consideration of MT in patients not meeting top tier evidence criteria may be warranted.
BackgroundEarly neurologic deterioration (END) following ischemic stroke is a serious event and is associated with poor outcomes. However, the incidence and predictors of END after stroke thrombectomy for emergent large vessel occlusion are largely unknown.MethodsThe baseline characteristics of patients enrolled in the COMPASS trial (NCT02466893) were analyzed. The primary outcome was worsening of ≥4 National Institutes of Health Stroke Scale (NIHSS) points 24 hours post thrombectomy (4+ END24) and the secondary outcome was deterioration of ≥2 points (2+ END24).ResultsAmong 270 patients, 27 (10%) developed 4+ END24 and 42 (16%) had 2+ END24. Those with 4+ END24 were older (76.4±12.9 vs 70.9±12.9 years; p=0.04), had a higher prevalence of hypertension (96% vs 69%; p=0.003), diabetes (41% vs 27%; p=0.13) and higher pretreatment systolic blood pressure (SBP) (170.4±32.6 vs 157.6±28.1 mmHg; p=0.03). More 4+ END24 patients had failed reperfusion: Thrombolysis in Cerebral Infarction ≤2a (26% vs 8%; p=0.003). In unadjusted analysis, older patients and those with hypertension, diabetes, elevated SBP and failed reperfusion had higher odds of 4+ END24. In adjusted analysis, age increase by 5 years led to an increase in 4+ END24 of 28%, diabetes increased odds of 2.6 and failed reperfusion increased odds of 4.5. In the multivariable analysis for the secondary outcome, age (OR 1.33; 95% CI 1.109 to 1.593), diabetes (OR 2.7; 95% CI 1.247 to 5.764) and failed reperfusion (OR 7.2; 95% CI 0.055 to 0.349) were also significant predictors of 2+ END24.ConclusionsOlder patients with acute ischemic stroke who have a history of diabetes or hypertension, with elevated pretreatment SBP and failed reperfusion are at a higher risk of END following stroke thrombectomy for emergent large vessel occlusion.
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Background: Recent recommendations for mechanical thrombectomy (MT) of acute ischemic stroke (AIS) patients with emergent large-vessel occlusions (ELVO) appropriately award top tier evidence (TTE) to the same selective criteria that were employed in recent clinical trials. We sought to evaluate the safety and efficacy of MT in AIS patients with ELVO who fail TTE criteria in a prospective multi-center study. Methods: Data on consecutive AIS patients with ELVO who underwent mechanical thrombectomy were collected from 6 high-volume endovascular centers. Standard safety and efficacy outcomes were compared between patients meeting and failing TTE criteria. Results: TTE criteria for MT were fulfilled in 349 (60%) cases (mean age 63±18 years; 47% men; median admission NIHSS-score 17 points, interquartile range 14-21), whereas 234 (40%) patients did not meet TTE criteria (mean age 62±19 years; 53% men; median admission NIHSS-score 16 points, interquartile range 9-21). (Table 1) The two most common reasons for failing TTE criteria were location of intracranial occlusion (n=144) and treatment window (n=108). In multivariate logistic regression models adjusting for potential confounders cases failing TTE criteria had similar safety (three-month mortality and symptomatic intracranial hemorrhage) and efficacy (three-month functional independence) outcomes with patients meeting TTE. Location of occlusion and proposed time-window according to TTE was also not related to any safety or efficacy outcome. (Table 2) Conclusions: Approximately 40% of AIS patients with ELVO offered MT do not fulfill TTE criteria for MT. Our multi-center experience indicates that MT may be offered to these patients with similar safety and efficacy to ELVO cases meeting TTE. Evidence-based medicine requires that health care providers understand published data and how those data might apply to a given patient’s treatment options. In a changing treatment environment this is a dynamic process.
Background & Purpose: Heart failure (HF) is a major risk factor for thromboembolism and first-ever stroke, and is associated with greater stroke severity and higher rates of early mortality and residual disability. There are limited data regarding the association of HF with stroke recurrence. We sought to evaluate the relationship between HF and recurrent IS stroke using a comprehensive meta-analytical approach. Methods: We performed a systematic literature review according to PRISMA guidelines to identify all prospective study protocols (randomized clinical trials or observational cohorts) that reported rates of IS recurrence in patients with concomitant HF. We pooled independently the reported corresponding risk ratios (RRs) and hazard ratios (HRs) from each study protocol using the random effects model. Results: Our literature search identified 7 eligible studies including 9,173 IS patients (18.2% with HF). The reported mean follow-up period in the included studies ranged from 7 days to 5 years. The pooled estimate of RRs and HRs for recurrent IS was 1.96 (95%CI: 1.49-2.60; p<0.0001; Figure, Caption A) and 1.93 (95%CI: 1.47-2.53; p<0.0001 Figure, Caption B). We found no evidence of heterogeneity within studies in both the RR (I2=13.5%, p for Cochran Q statistic: 0.325) and HR (I2=0%, p for Cochran Q statistic: 0.629) analyses. Conclusions: HF is associated with a continuous two-fold increase in the risk of IS recurrence in patients with prior history of cerebral ischemia. The benefit of anticoagulation in this high-risk group of patients may be studied along with additional risk factor modifications.
GE Healthcare©announced on April 19, 2022, that their main factory and distributor of iodinated contrast had experienced a temporary shutdown because of COVID-19 outbreak in Shanghai, China. This, along with other supply chain issues, led to a worldwide shortage of iodinated contrast agents, Omnipaque and Visipaque. Our Comprehensive Stroke Center was confronted with the cascading effect of this iodinated contrast material shortage. We took immediate steps to revise our protocols and processes to continue to provide high-quality care to our stroke patients. A multidisciplinary working group comprised of representatives of our stroke center, including vascular neurology, diagnostic neuroradiology, and neurovascular surgery, urgently met to brainstorm how to mitigate the shortage. We established parameters and local guidelines for the use of CT angiography, CT perfusion, and digital subtraction angiography for stroke patients. In this article, we propose “best practice” recommendations from a single Joint Commission approved Comprehensive Stroke Center that can be used as blueprint by other hospital systems when navigating potential future supply chain issues, to provide consistent high-quality stroke care.
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