Background and Purpose: Social networks influence human health and disease through direct biological and indirect psychosocial mechanisms. They have particular importance in neurologic disease because of support, information, and healthy behavior adoption that circulate in networks. Investigations into social networks as determinants of disease risk and health outcomes have historically relied on summary indices of social support, such as the Lubben Social Network Scale–Revised (LSNS-R) or the Stroke Social Network Scale (SSNS). We compared these 2 survey tools to personal network (PERSNET) mapping tool, a novel social network survey that facilitates detailed mapping of social network structure, extraction of quantitative network structural parameters, and characterization of the demographic and health parameters of each network member. Methods: In a cohort of inpatient and outpatient stroke survivors, we administered LSNS-R, SSNS, and PERSNET in a randomized order to each patient. We used logistic regression to generate correlation matrices between LSNS-R scores, SSNS scores, and PERSNET’s network structure (eg, size and density) and composition metrics (eg, percent kin in network). We also examined the relationship between LSNS-R-derived risk of social isolation with PERSNET-derived network size. Results: We analyzed survey responses for 67 participants and found a significant correlation between LSNS-R, SSNS, and PERSNET-derived indices of network structure. We found no correlation between LSNS-R, SSNS, and PERSNET-derived metrics of network composition. Personal network mapping tool structural and compositional variables were also internally correlated. Social isolation defined by LSNS-R corresponded to a network size of <5. Conclusions: Personal network mapping tool is a valid index of social network structure, with a significant correlation to validated indices of perceived social support. Personal network mapping tool also captures a novel range of health behavioral data that have not been well characterized by previous network surveys. Therefore, PERSNET offers a comprehensive social network assessment with visualization capabilities that quantifies the social environment in a valid and unique manner.
BACKGROUND For acute proximal intracranial artery occlusions, contact aspiration may be more effective than stent‐retriever for first‐line reperfusion therapy. Due to the lack of data regarding medium vessel occlusion thrombectomy, we evaluated outcomes according to first‐line technique in a large, multicenter registry. METHODS Imaging, procedural, and clinical outcomes of patients with acute proximal medium vessel occlusions (M2, A1, or P1) or distal medium vessel occlusions (M3, A2, P2, or further) treated at 37 sites in 10 countries were analyzed according to first‐line endovascular technique (stent‐retriever versus aspiration). Multivariable logistic regression and propensity‐score matching were used to estimate the odds of the primary outcome, expanded Thrombolysis in Cerebral Infarction score of 2b–3 (“successful recanalization”), as well as secondary outcomes (first‐pass effect, expanded Thrombolysis in Cerebral Infarction 2c‐3, intracerebral hemorrhage, and 90‐day modified Rankin scale, 90‐day mortality) between treatment groups. RESULTS Of the 440 included patients (44.5% stent‐retriever versus 55.5% aspiration), those treated with stent‐retriever had lower baseline Alberta Stroke Program Early Computed Tomography Scale scores (median 8 versus 9; P <0.01), higher National Institutes of Health Stroke Scale scores (median 13 versus 11; P =0.02), and nonsignificantly fewer medium‐distal occlusions (M3, A2, P2, or other: 17.4% versus 23.8%; P =0.10). Use of a stent‐retriever was associated with 15% lower odds of successful recanalization (odds ratio [OR], 0.85; [95% CI 0.74–0.98]; P =0.02), but this was not significant after multivariable adjustment in the total cohort (adjusted OR, 0.88; [95% CI 0.72–1.09]; P =0.24), or in the propensity‐score matched cohort (n=105 in each group) (adjusted OR, 0.94; [95% CI 0.75–1.18]; P =0.60). There was no significant association between technique and secondary outcomes in the propensity‐score matched adjusted models. CONCLUSION In this large, diverse, multinational medium vessel occlusion cohort, we found no significant difference in imaging or clinical outcomes with aspiration versus stent‐retriever thrombectomy.
Introduction: The evaluation and risk stratification of patients with TIA/non-disabling ischemic stroke (TIA/NDS) arriving to the Emergency Department (ED) incurs high-cost imaging and increases ED length of stay (EDLOS). We evaluated the safety and feasibility of an ED-to-Outpatient Pathway for TIA/NDS. Methods: In April 2020, we developed a risk stratification algorithm for TIA/NDS in the ED using features of the clincal presentation, limited blood tests, telemetry, and head-neck CT/CTA. Patients deemed low risk based on a “safety checklist” were discharged with plans for expedited outpatient testing as warranted (e.g., brain MRI, echocardiogram) followed by rapid outpatient follow-up. To assess safety/feasibility of this pathway, we analyzed data of the first 101 patients prospectively enrolled through October 2020. Results: Mean age 68 years (range, 33-99); 53% men; median NIHSS score 0 (range 0-3). Symptom duration was classified as <10 min (24%), 10-59 min (23%), >60 min (49%), unclear (4%). Deficits included isolated weakness (16%), isolated aphasia (15%), amaurosis fugax (6%), numbness/combined deficits/other (63%). Median ABCD2 score 3 (range 1-7). Outpatient follow-up included stroke clinic (82%), primary care (4%), not required or patient declined (6%), other hospital (1%); 7% were lost to follow-up; 43% had follow-up within 7 days. Imaging performed in the ED included CT/CTA only (39%), MRI/MRA only (27%), both (33%), or no imaging (1%). EDLOS was significantly less for patients when CT/CTA only was performed, as per pathway (12.8 versus 16.8 hours, p<0.05). The safety checklist was followed in 69% of patients. When the checklist was used properly, there were 0 recurrent strokes or TIAs within 90-days (versus 2 when not used correctly, p<0.05). Return rates to the ED were 8% with use of checklist and 6% without use (p=0.76). Conclusion: Our TIA/NDS pathway, implemented shortly after the outbreak of Covid-19 in the USA, significantly decreased EDLOS, and still allowed for TIA/NDS patients to be safely discharged from the ED. Acceptable risk stratification and safety is suggested by the low rates of recurrent events when the pathway was followed properly. More education is needed to ensure consistent and proper use of the pathway.
Introduction In the last several years,there has been a paradigm shift in treating patients presenting with large vessel occlusion (LVO) strokes with endovascular therapy (EVT). Currently, the 24‐hour window has been incorporated in acute stroke management guidelines based on trials supporting the selection of patients with evidence of ischemic penumbra on perfusion imaging1,2. No current randomized control trials exist to support very late window EVT (beyond 24 hours) from last seen well (LSW) and its benefits are unknown. Several retrospective studies showed that EVT is safe and feasible up to 6 days from LSW in selected patients who are able preserve a favorable ischemic core to penumbra3, 4, 5. In this study we present a retrospective review of three patients with LVO strokes of the anterior circulation successfully treated between 10–14 days from LSW. We aim to explore the safety, efficiency and positive predictors of very late window EVT. Methods A single center retrospective review of stroke patients was performed. 517 patients with LVO strokes who underwent EVT between January 2018 and December 2021 were screened. 3 patients were found to have EVT performed 24 hours beyond LSW. Patient demographics, characteristics and clinical information were collected by systematic chart review. The primary outcome was functional independence as assessed by the modified Rankin Score (mRS) at 90 days. The safety outcomes included neurological deterioration and symptomatic intracranial hemorrhage, defined as an increase in National Institutes of Health Stroke Scale (NIHSS) of 4 or more). Further, a comprehensive literature review of studies describing very late window EVT cases indexed in PubMed was performed. Results We identifiedthree patients with LVO strokes, treated more than 24 hours from LSW. Patient ages ranged from 75 to 89 years. Baseline NIHSS ranged from 1 to 13. All patients had LVO or stenosis of the anterior circulation (internal carotid artery and/or M1 segment of the middle cerebral artery). All patients had fluctuation in their symptoms with worsening going from a supine position to a sitting position, evidence of ischemic penumbra on perfusion imaging and slow infarct growth on repeat brain imaging. The time from LSW to intervention ranged from 11 to 14 days. Recanalization score ranged from 2B‐3. No patients had intracranial hemorrhage or neurological decline. mRS scores were 2, 4, and 6 at 3 months. The patient who died had preservation of neurological function but died in the hospital due to heart failure. Conclusions We conclude that widening of the EVT time window presents new opportunities to treat a select population of LVO stroke patients. To our knowledge, there are no other reports of EVT in LVO patients beyond 10 days of LSW. Patients who have evidence of large ischemic penumbra, fluctuation of symptoms with change in position or blood pressure, good collateral circulation, and small infarct core that grows slowly on repeat imaging may be reasonable candidates for delayed EVT. More data are needed to inform clinical practice.
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