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Stroke
Journal Prestige (SJR): 3.529
Citation Impact (citeScore): 5
Number of Followers: 97  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0039-2499 - ISSN (Online) 1524-4628
Published by American Heart Association Homepage  [12 journals]
  • Correction to: Blood Pressure After Endovascular Thrombectomy: Modeling
           for Outcomes Based on Recanalization Status

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      Abstract: Stroke, Volume 52, Issue 10, Page e701-e701, October 1, 2021.

      Citation: Stroke
      PubDate: 2021-09-27T06:00:06Z
      DOI: 10.1161/STR.0000000000000391
      Issue No: Vol. 52, No. 10 (2021)
       
  • October 2021 Stroke Highlights

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      Authors: Nicole B. Sur
      Pages: 3081 - 3081
      Abstract: Stroke, Volume 52, Issue 10, Page 3081-3081, October 1, 2021.

      Citation: Stroke
      PubDate: 2021-09-27T06:00:06Z
      DOI: 10.1161/STROKEAHA.121.037103
      Issue No: Vol. 52, No. 10 (2021)
       
  • Economic Evaluation of Endovascular Treatment for Acute Ischemic Stroke

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      Authors: Lucie A. van den Berg Olvert A. Berkhemer Puck S.S. Fransen Debbie Beumer Hester Lingsma Charles B.M. Majoie Diederik W.J. Dippel Aad van der Lugt Robert J. van Oostenbrugge Wim H. van Zwam Yvo B. Roos Marcel G.W. Dijkgraaf Departments of Neurology; Amsterdam University Medical Center, the Netherlands. (L.A.v.d.B., Y.B.R.) Clinical Epidemiology, Biostatistics, Nuclear Medicine, Amsterdam University Medical Center, the Netherlands. (C.B.M.M., O.A.B.) Department of Neurology, Erasmus MC University Medical Center Rotterdam, the Netherlands. (O.A.B., P.S.S.F., D.W.J.D.) Department of Radiology, Erasmus MC University Medical Center Rotterdam, the Netherlands. (O.A.B., A.v.d.L.) Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands. (H.L.) Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands. (D.B., R.J.v.O.) Department of Radiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands. (O.A.B., W.H.v.Z.) , on behalf of the MR CLEAN Investigators Albert J. Yoo Wouter J. Schonewille Jan Albert Vos Paul J. Nederkoorn Marieke J.H. Wermer Marianne A.A. van Walderveen Julie Staals Jeannette Hofmeijer Jacques A. van Oostayen Geert J. Lycklama à Nijeholt Jelis Boiten Patrick A. Brouwer Bart J. Emmer Sebastiaan F. de Bruijn Lukas C. van Dijk L. Jaap Kappelle Rob H. Lo Ewoud J. van Dijk Joost de Vries Paul L.M. de Kort Jan S.P. van den Berg Boudewijn A.A.M. van Hasselt Leo A.M. Aerden René J. Dallinga Marieke C. Visser Joseph C.J. Bot Patrick C. Vroomen Omid Eshghi Tobien H.C.M.L. Schreuder Roel J.J. Heijboer Koos Keizer Alexander V. Tielbeek Heleen M. den Hertog Dick G. Gerrits Renske M. van den Berg-Vos Giorgos B. Karas Ewout W. Steyerberg H. Zwenneke Flach Henk A. Marquering Marieke E.S. Sprengers Sjoerd F.M. Jenniskens Ludo F.M. Beenen René van den Berg Peter J. Koudstaal
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Endovascular treatment for acute ischemic stroke has been proven clinically effective, but evidence of the cost-effectiveness based on real-world data is scarce. The aim of this study was to assess whether endovascular therapy plus usual care is cost-effective in comparison to usual care alone in acute ischemic stroke patients.Methods:An economic evaluation was performed from a societal perspective with a 2-year time horizon. Empirical data on health outcomes and the use of resources following endovascular treatment were gathered parallel to the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) and its 2-year follow-up study. Incremental cost-effectiveness ratios were calculated as the extra costs per additional patient with functional independence (modified Rankin Scale score 0–2) and the extra cost per quality-adjusted life year gained.Results:The mean costs per patient in the intervention group were $126 494 versus $143 331 in the control group (mean difference, −$16 839 [95% CI, −$38 113 to $5456]). Compared with patients in the control group, more patients in the intervention group achieved functional independence, 37.2% versus 23.9% (absolute difference, 13.3% [95% CI, 4.0%–22.0%]) and they generated more quality-adjusted life years, 0.99 versus 0.83 (mean difference of 0.16 [95% CI, 0.04–0.29]). Endovascular treatment dominated standard treatment with $18 233 saved per extra patient with a good outcome and $105 869 saved per additional quality-adjusted life year.Conclusions:Endovascular treatment added to usual care is clinically effective, and cost saving in comparison to usual care alone in patients with acute ischemic stroke.REGISTRATION:URL:https://www.trialregister.nl/trial/695; Unique identifier: NL695.https://www.isrctn.com/ISRCTN10888758; Unique identifier: ISRCTN10888758.
      Citation: Stroke
      PubDate: 2021-10-14T09:00:26Z
      DOI: 10.1161/STROKEAHA.121.034599
       
  • Frequency and Prognostic Significance of Clinical Fluctuations Before
           Hospital Arrival in Stroke

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      Authors: Jose G. Romano Hannah Gardener Eric E. Smith Iszet Campo-Bustillo Yosef Khan Sofie Tai Nikesha Riley Ralph L. Sacco Pooja Khatri Heather M. Alger Brian Mac Grory Deepak Gulati Navdeep S. Sangha Karin E. Olds Curtis G. Benesch Adam G. Kelly Scott S. Brehaut Amit C. Kansara Lee H. Schwamm University of Miami Miller School of Medicine; FL (J.G.R., H.G., I.C.-B., R.L.S.). Department of Clinical Neurosciences Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.). American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.). University of Cincinnati, OH (P.K.). Duke University School of Medicine, Durham, NC (B.M.G.). Ohio State University Wexner Medical Center, Columbus (D.G.). Kaiser Permanente/Los Angeles Medical Center, CA (N.S.S.). St. Luke’s Hospital, Kansas City, MO (K.E.O.). University of Rochester Medical Center, NY (C.G.B., A.G.K.). Faxton St. Luke’s Healthcare, Utica, NY (S.S.B.). Providence St. Vincent Medical Center, Portland, OR (A.C.K.). Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.). , on behalf of the MaRISS Investigators Scott Moody Weiping Ye Vena Sobhawongse Jeffrey M. Craig Heloisa Pearson Deborah Summers Christine Boerman Christy Rice Robin Kintner Mayumi Oka Sarah Baran Christina Roels Maureen Dosunmu Cherylee W. J. Chang Jennifer Moran Denise Ditrich Nicholas Lanciano Aimee Mann Charles E. Romero Becky Thiele David Salvatore Annette Taylor Neel Shah Rodney Leacock Angel Rochester Fanny Guillerminet Jerry C. Martin Johnny Jones Nicol Brandon Vikas Grover Maryika Gibson Maheen Malik Carol Mechem William R. Logan Camilla Cook Muhib A Khan Christa Rood Arun Babu Leah Steinig Jestin Carlson Melanie Henderson Gabriel Vidal Bethany Jennings Jennifer Lynch Jessica Ratcliff Kathryn Kirchoff Khadean Moncrieffe Jennifer Rasmussen-Winkler Leigh Allen Gary Thompson Christopher Firek Stephen Martino Baher Georgy Gillian L. Gordon-Perue Nina Vekima Kasey Gildersleeve Marian Skewes Christina Valdovinos Timothy C. Parsons Cynthia Marques John W. Chen David Lombardi Brenda Perez Amer Malik Kathy Hesse Amy Guzik Sandra E. Norona Robert Hoesch Jacki Anderson Dorothea Altschul Farah Fermin Miran Salgado Jonathan Muller Indrani Acosta Brooke Hartwell Terry A. Neill Carrie Hundley Abhineet Chowdhary Tina Fortney Jose Rafael Romero Brandon Finn Refat Assad Maggie Ellithorpe Rebecca Sugg Susan Hetzel Muhammad M. Alvi Jay Sherman Jonathan Hartman Tashia Orr Ankur Garg Melissa Turner Curtis Given Sara Renfrow Jeffrey Hilburn Ellen Looney Christopher Commichau Paul Jarvis Changsoo Hahm Melissa Mccaulley Angel Pulido Sergio Michel Nima Ramezan-Arab Françoise Toussaint- Jones Anna Khanna Esther Olasoji Armistead Williams Elizabeth Purrington Ratna Reddy Renee Potter Bhupat Desai Karen Tse-Chang Laurence Ufford Leslie Drager Keith O. Jones Teresa Ellebusch Stephen Martino Michelle Dobrzynski Elizabeth H. Wise Ann Jerde Gauhar Chaudhary Robyn McLean Joseph Hanna Dana Cook Franklin Marden Jennifer Orde Ajay Arora Shawna Miller Raymond Reichwein Deborah Hoffman Kelly Matmati Nabil Matmati Kumiko Owada Laura Murphy Ashish Masih Bethany Fife Larry Shepherd Matthew Holzmann Stephen Gancher Sabrina Enoch Matthew Smith Denise Goings Joseph Mazzola Edward Plyler Lisa Landers James Napier Laura Thoreson Amer Alshekhlee Michelle Raymond Tarakad Ramachandran Michael Jorolemon David Padalino Collin Maloney Jenny Rae Mott Laxmi P. Dhakal Cindy Murphy Truman J. Milling Patrick Lawrence Harish Shownkeen Kathy Hansen Paul A. Cullis Lynne Froehlich Sajjad Mueed Ryan Pavolka Steven R. Levine Nadege Gilles Truman J. Milling Laura LaChance Kanwal Nayyar Karen Klein Rose Dotson Kristopher Rowe Elisheva Coleman Emily Sayles Rajan Gadhia Jason Lee Paul W. Lewis Jenny Nunley Rehan Sajjad Carol Halliday Angelos Katramados Theresa Holmes Rashmikant Kothari Linda Mader Fen Lei Chang Kelly Western Kinjal Desai Colleen Kehr Gary Reese Ashu Jadhav Mackenzie Steinbach Jeffrey Saver Gilda Avila Janice A. Miller Alicia Gneiting Matthew S. Tenser Sarah Burke
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Clinical fluctuations in ischemic stroke symptoms are common, but fluctuations before hospital arrival have not been previously characterized.Methods:A standardized qualitative assessment of fluctuations before hospital arrival was obtained in an observational study that enrolled patients with mild ischemic stroke symptoms (National Institutes of Health Stroke Scale [NIHSS] score of 0–5) present on arrival to hospital within 4.5 hours of onset, in a subset of 100 hospitals participating in the Get With The Guidelines–Stroke quality improvement program. The number of fluctuations, direction, and the overall improvement or worsening was recorded based on reports from the patient, family, or paramedics. Baseline NIHSS on arrival and at 72 hours (or discharge if before) and final diagnosis and stroke subtype were collected. Outcomes at 90 days included the modified Rankin Scale, Barthel Index, Stroke Impact Scale 16, and European Quality of Life. Prehospital fluctuations were examined in relation to hospital NIHSS change (admission to 72 hours or discharge) and 90-day outcomes.Results:Among 1588 participants, prehospital fluctuations, consisting of improvement, worsening, or both were observed in 35.5%: 25.1% improved once, 5.3% worsened once, and 5.1% had more than 1 fluctuation. Those who improved were less likely and those who worsened were more likely to receive alteplase. Those who improved before hospital arrival had lower change in the hospital NIHSS than those who did not fluctuate. Better adjusted 90-day outcomes were noted in those with prehospital improvement compared to those without any fluctuations.Conclusions:Fluctuations in neurological symptoms and signs are common in the prehospital setting. Prehospital improvement was associated with better 90-day outcomes, controlling for admission NIHSS and alteplase treatment.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT 02072681.
      Citation: Stroke
      PubDate: 2021-10-14T09:00:26Z
      DOI: 10.1161/STROKEAHA.121.034124
       
  • HDL (High-Density Lipoprotein) Subspecies, Prevalent Covert Brain
           

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      Authors: Manja Koch Sarah A. Aroner Annette L. Fitzpatrick W.T. Longstreth Jeremy D. Furtado Kenneth J. Mukamal Majken K. Jensen Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA (M.K; S.A.A, J.D.F, K.J.M, M.K.J.). Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (S.A.A.). Department of Family Medicine, University of Washington, Seattle. (A.L.F.) Department of Epidemiology, University of Washington, Seattle. (A.L.F.) Department of Global Health, University of Washington, Seattle. (A.L.F.) Department of Neurology, University of Washington, Seattle. (W.T.L.) Department of Epidemiology, University of Washington, Seattle. (W.T.L.) Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.). Department of Public Health, Section of Epidemiology, University of Copenhagen, Denmark (M.K.J.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Whether HDL (high-density lipoprotein) is associated with risk of vascular brain injury is unclear. HDL is comprised of many apo (apolipoprotein) species, creating distinct subtypes of HDL.Methods:We utilized sandwich ELISA to determine HDL subspecies from plasma collected in 1998/1999 from 2001 CHS (Cardiovascular Health Study) participants (mean age, 80 years).Results:In cross-sectional analyses, participants with higher apoA1 in plasma and lower apoE in HDL were less likely to have prevalent covert magnetic resonance imaging–defined infarcts: odds ratio for apoA1 Q4 versus Q1, 0.68 (95% CI, 0.50–0.93), and odds ratio for apoE Q4 versus Q1, 1.36 (95% CI, 1.01–1.84). Similarly, apoA1 in the subspecies of HDL that lacked apoC3, apoJ, or apoE was inversely related to covert infarcts, and apoE in the subspecies of HDL that lacked apoC3 or apoJ was directly related to covert infarcts in prospective analyses. In contrast, the concentrations of apoA1 and apoE in the complementary subspecies of HDL that contained these apos were unrelated to covert infarcts. Patterns of associations between incident overt ischemic stroke and apoA1, apoE, and apoA1 and apoE in subspecies of HDL were similar to those observed for covert infarcts but less pronounced.Conclusions:This study highlights HDL subspecies defined by apo content as relevant biomarkers of covert and overt vascular brain injury.
      Citation: Stroke
      PubDate: 2021-10-14T09:00:26Z
      DOI: 10.1161/STROKEAHA.121.034299
       
  • Prevalence and Prognostic Significance of Malnutrition Risk in Patients
           With Acute Ischemic Stroke: Results From the Third China National Stroke
           Registry

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      Authors: Guitao Zhang Yuesong Pan Runhua Zhang Mengxing Wang Xia Meng Zixiao Li Hao Li Yilong Wang Xingquan Zhao Gaifen Liu Yongjun Wang Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (G.Z; Y.P, R.Z, X.M, Z.L, H.L, Yilong Wang, X.Z, G.L, Yongjun Wang) Beijing Institute of Brain Disorders, Capital Medical University, China. (G.L.) China National Clinical Research Center for Neurological Diseases, Beijing, China (Y.P, R.Z, M.W, X.M, Z.L, H.L, Yilong Wang, X.Z, G.L, Yongjun Wang),
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:To investigate the prevalence of malnutrition risk in patients with acute ischemic stroke (AIS) at admission, the association between malnutrition risk and long-term outcomes, and whether the predictive ability would be improved after adding to previous prognostic models for poor outcomes.Methods:Based on the Third China National Stroke Registry data from August 2015 to March 2018, we evaluated malnutrition risk using objective scores, including the controlling nutritional status score, geriatric nutritional risk index, and prognostic nutritional index. The primary outcome was death or major disability (modified Rankin Scale score ≥3) at 1 year after stroke onset. We calculated the crude prevalence of malnutrition risk and investigated the association between malnutrition risk and clinical outcomes. Prognostic performance of 3 objective malnutrition scores for poor outcomes was assessed.Results:Moderate to severe malnutrition risk was identified in 5.89%, 5.30%, and 1.95% of the Third China National Stroke Registry AIS patients according to the controlling nutritional status score, geriatric nutritional risk index, and prognostic nutritional index, respectively. At 1-year follow-up, 1143 participants (13.5%) experienced death or major disability. After adjustment for traditional risk factors, moderate to severe malnutrition risk was associated with high risk of composite events (odds ratio, 2.25 [95% CI, 1.75–2.90], for controlling nutritional status score; odds ratio, 2.10 [95% CI, 1.63–2.69], for geriatric nutritional risk index; odds ratio, 3.36 [95% CI, 2.33–4.84], for prognostic nutritional index; allP<0.01). Addition of the 3 malnutrition scores to different predicted scales (iScore and Acute Stroke Registry and Analysis of Lausanne) improved predictive ability for long-term poor outcomes validated by the integrated discrimination index (allP<0.05).Conclusions:The prevalence of moderate or severe malnutrition risk in Chinese patients with AIS ranged from 1.95% to 5.89%. Malnutrition risk in patients with AIS was associated with increased risk of long-term death and major disability. Our study provides evidence supporting the prognostic significance of objective malnutrition scores after AIS.
      Citation: Stroke
      PubDate: 2021-10-14T09:00:26Z
      DOI: 10.1161/STROKEAHA.121.034366
       
  • Hematoma Expansion and Clinical Outcomes in Patients With Factor-Xa
           Inhibitor–Related Atraumatic Intracerebral Hemorrhage Treated Within the
           ANNEXA-4 Trial Versus Real-World Usual Care

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      Authors: Hagen B. Huttner Stefan T. Gerner Joji B. Kuramatsu Stuart J. Connolly Jan Beyer-Westendorf Andrew M. Demchuk Saskia Middeldorp Elena Zotova Julia Altevers Frank Andersohn Mary J. Christoph Patrick Yue Leonhard Stross Stefan Schwab Department of Neurology; University Hospital Erlangen, Germany (H.B.H., S.T.G., J.B.K., S.S.). Department of Neurology, University Hospital Giessen, Germany (H.B.H.). Population Health Research Institute, McMaster University, Canada (S.J.C., E.Z.). Department of Medicine, Dresden University Clinic Fetscherstr, Germany (J.B.-W.). Department of Clinical Neurosciences, University of Calgary, Canada. (A.M.D.) Department of Radiology, University of Calgary, Canada. (A.M.D.) Department of Internal Medicine Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (S.M.). Xcenda GmbH, Germany (J.A., F.A.). Portola Pharmaceuticals, Inc (now Alexion, AstraZeneca Rare Disease), Boston, MA (M.J.C.). Former employee of Portola Pharmaceuticals, Inc (now Alexion, AstraZeneca, Rare Disease), Boston, MA (P.Y., L.S.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:It is unestablished whether andexanet alfa, compared with guideline-based usual care including prothrombin complex concentrates, is associated with reduced hematoma expansion (HE) and mortality in patients with factor-Xa inhibitor–related intracerebral hemorrhage (ICH). We compared the occurrence of HE and clinical outcomes in patients treated either with andexanet alfa or with usual care during the acute phase of factor-Xa inhibitor–related ICH.Methods:Data were extracted from the multicenter, prospective, single-arm ANNEXA-4 trial (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors) and a multicenter observational cohort study, RETRACE-II (German-Wide Multicenter Analysis of Oral Anticoagulant-Associated Intracerebral Hemorrhage - Part Two). HE was based on computed tomography scans performed within 36 hours from baseline imaging. Inverse probability of treatment weighting was performed to adjust for baseline comorbidities and ICH severity. Patients presenting with atraumatic ICH while receiving apixaban or rivaroxaban within 18 hours of admission were included. Patients with secondary ICH or not fulfilling the inclusion criteria for the ANNEXA-4 trial were excluded. We compared ANNEXA-4 patients, who received andexanet alfa for hemostatic treatment, with RETRACE-II patients who were treated with usual care, primarily administration of prothrombin complex concentrates. Primary outcome was rate of HE defined as relative increase of ≥35%. Secondary outcomes comprised mean absolute change in hematoma volume, as well as in-hospital mortality and functional outcome.Results:Overall, 182 patients with factor-Xa inhibitor–related ICH (85 receiving andexanet alfa versus 97 receiving usual care) were selected for analysis. There were no relevant differences regarding demographic or clinical characteristics between both groups. HE occurred in 11 of 80 (14%) andexanet alfa patients compared with 21 of 67 (36%) usual care patients (adjusted relative risk, 0.40 [95% CI, 0.20–0.78];P=0.005), with a reduction in mean overall hematoma volume change of 7 mL. There were no statistically significant differences among in-hospital mortality or functional outcomes. Sensitivity analysis including only usual care patients receiving prothrombin complex concentrates demonstrated consistent results.Conclusions:As compared with usual care, andexanet alfa was associated with a lower rate of HE in atraumatic factor-Xa inhibitor–related ICH, however, without translating into significantly improved clinical outcomes. A comparative trial is needed to confirm the benefit on limiting HE and to explore clinical outcomes across patient subgroups and by time to treatment.
      Citation: Stroke
      PubDate: 2021-10-14T09:00:26Z
      DOI: 10.1161/STROKEAHA.121.034572
       
  • External Validation of Risk Prediction Models to Improve Selection of
           Patients for Carotid Endarterectomy

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      Authors: Michiel H.F. Poorthuis Reinier A.R. Herings Kirsten Dansey Johanna A.A. Damen Jacoba P. Greving Marc L. Schermerhorn Gert J. de Borst Department of Neurology; University Medical Center Utrecht, the Netherlands. (M.H.F.P.) Julius Center for Health Sciences Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (K.D., M.L.S.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The net benefit of carotid endarterectomy (CEA) is determined partly by the risk of procedural stroke or death. Current guidelines recommend CEA if 30-day risks are <6% for symptomatic stenosis and <3% for asymptomatic stenosis. We aimed to identify prediction models for procedural stroke or death after CEA and to externally validate these models in a large registry of patients from the United States.Methods:We conducted a systematic search in MEDLINE and EMBASE for prediction models of procedural outcomes after CEA. We validated these models with data from patients who underwent CEA in the American College of Surgeons National Surgical Quality Improvement Program (2011–2017). We assessed discrimination using C statistics and calibration graphically. We determined the number of patients with predicted risks that exceeded recommended thresholds of procedural risks to perform CEA.Results:After screening 788 reports, 15 studies describing 17 prediction models were included. Nine were developed in populations including both asymptomatic and symptomatic patients, 2 in symptomatic and 5 in asymptomatic populations. In the external validation cohort of 26 293 patients who underwent CEA, 702 (2.7%) developed a stroke or died within 30-days. C statistics varied between 0.52 and 0.64 using all patients, between 0.51 and 0.59 using symptomatic patients, and between 0.49 to 0.58 using asymptomatic patients. The Ontario Carotid Endarterectomy Registry model that included symptomatic status, diabetes, heart failure, and contralateral occlusion as predictors, had C statistic of 0.64 and the best concordance between predicted and observed risks. This model identified 4.5% of symptomatic and 2.1% of asymptomatic patients with procedural risks that exceeded recommended thresholds.Conclusions:Of the 17 externally validated prediction models, the Ontario Carotid Endarterectomy Registry risk model had most reliable predictions of procedural stroke or death after CEA and can inform patients about procedural hazards and help focus CEA toward patients who would benefit most from it.
      Citation: Stroke
      PubDate: 2021-10-12T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.032527
       
  • Antiplatelet Use and Ischemic Stroke Risk in Minor Stroke or Transient
           Ischemic Attack: A Post Hoc Analysis of the POINT Trial

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      Authors: Mohammad Anadani Adam de Havenon Nils Henninger Lindsey Kuohn Brian Mac Grory Karen L. Furie Anthony S. Kim J. Donald Easton S. Claiborne Johnston Shadi Yaghi Department of Neurology, Washington University in Saint Louis, MO (M.A.). Department of Neurology, University of Utah Medical Center, Salt Lake City (A.d.H.). Department of Neurology, University of Massachusetts Medical Center, Worcester. (N.H.) Department of Psychiatry, University of Massachusetts Medical Center, Worcester. (N.H.) NYU Grossman School of Medicine, New York, NY (L.K.). Department of Neurology, Duke University, Durham, NC (B.M.G.). Department of Neurology, Brown University, Providence, RI (K.L.F; S.Y.). Department of Neurology, University of California, San Francisco (A.S.K, J.D.E.). Dean’s Office, Dell Medical School, The University of Texas at Austin (S.C.J.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Dual antiplatelet therapy has been shown to reduce the risk of recurrent stroke in patients with minor stroke or transient ischemic attack. However, whether the effect of dual antiplatelet therapy is modified by pretreatment antiplatelet status is unclear.Methods:This is a post hoc analysis of the POINT trial (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke). Patients were divided into 2 groups based on pretreatment antiplatelet use. The primary outcome was ischemic stroke within 90 days of randomization.Results:We included 4881 patients of whom 41% belonged to the no pretreatment antiplatelet. Ischemic stroke occurred in 6% and 5% in the antiplatelet pretreatment and no antiplatelet pretreatment, respectively. Antiplatelet pretreatment was not associated with the risk of ischemic stroke (adjusted hazard ratio, 1.05 [95% CI, 0.81–137]) or risk of major hemorrhage (hazard ratio, 1.10 [95% CI, 0.55–2.21];P=0.794). The effect of dual antiplatelet therapy on recurrent ischemic stroke risk was not different in patients who were on antiplatelet before randomization (adjusted hazard ratio, 0.69 [95% CI, 0.50–0.94]) as opposed to those who were not (adjusted hazard ratio, 0.75 [95% CI, 0.50–1.12]),Pfor interaction = 0.685.Conclusions:In patients with minor stroke and high-risk transient ischemic attack, dual antiplatelet therapy reduces the risk of ischemic stroke regardless of premorbid antiplatelet use.
      Citation: Stroke
      PubDate: 2021-10-12T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.035354
       
  • Repeat Flow Diversion for Cerebral Aneurysms Failing Prior Flow Diversion:
           Safety and Feasibility From Multicenter Experience

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      Authors: Mohamed M. Salem Ahmad Sweid Anna L. Kuhn Adam A. Dmytriw Santiago Gomez-Paz Georgios A. Maragkos Muhammad Waqas Carmen Parra-Farinas Arsalaan Salehani Nimer Adeeb Patrick Brouwer Gwynedd Pickett Jerry Ku Victor X.D. Yang Alain Weill Ivan Radovanovic Christophe Cognard Julian Spears Hugo H. Cuellar-Saenz Leonardo Renieri Peter Kan Nicola Limbucci Vitor Mendes Pereira Mark R. Harrigan Ajit S. Puri Elad I. Levy Justin M. Moore Christopher S. Ogilvy Thomas R. Marotta Pascal Jabbour Ajith J. Thomas Division of Neurosurgery; Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.). Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA (A.S., P.J.). Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester (A.L.K., A.S.P.). Department of Medical Imaging Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.). Department of Interventional Neuroradiology, University of Florence, Florence, Italy (L.R., N.L.). Department of Neurosurgery, Baylor College of Medicine, Houston, TX (P.K.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Aneurysmal persistence after flow diversion (FD) occurs in 5% to 25% of aneurysms, which may necessitate retreatment. There are limited data on safety/efficacy of repeat FD—a frequently utilized strategy in such cases.Methods:A series of consecutive patients undergoing FD retreatment from 15 centers were reviewed (2011–2019), with inclusion criteria of repeat FD for the same aneurysm at least 6 months after initial treatment, with minimum of 6 months post-retreatment imaging. The primary outcome was aneurysmal occlusion, and secondary outcome was safety. A multivariable logistic regression model was constructed to identify predictors of incomplete occlusion (90%–99% and <90% occlusion) versus complete occlusion (100%) after retreatment.Results:Ninety-five patients (median age, 57 years; 81% women) harboring 95 aneurysms underwent 198 treatment procedures. Majority of aneurysms were unruptured (87.4%), saccular (74.7%), and located in the internal carotid artery (79%; median size, 9 mm). Median elapsed time between the first and second treatment was 12.2 months. Last available follow-up was at median 12.8 months after retreatment, and median 30.6 months after the initial treatment, showing complete occlusion in 46.2% and near-complete occlusion (90%–99%) in 20.4% of aneurysms. There was no difference in ischemic complications following initial treatment and retreatment (4.2% versus 4.2%;P>0.99). On multivariable regression, fusiform morphology had higher nonocclusion odds after retreatment (odds ratio [OR], 7.2 [95% CI, 1.97–20.8]). Family history of aneurysms was associated with lower odds of nonocclusion (OR, 0.18 [95% CI, 0.04–0.78]). Likewise, positive smoking history was associated with lower odds of nonocclusion (OR, 0.29 [95% CI, 0.1–0.86]). History of hypertension trended toward incomplete occlusion (OR, 3.10 [95% CI, 0.98–6.3]), similar to incorporated branch into aneurysms (OR, 2.78 [95% CI, 0.98–6.8]).Conclusions:Repeat FD for persistent aneurysms carries a reasonable success/safety profile. Satisfactory occlusion (100% and 90%–99% occlusion) was encountered in two-thirds of patients, with similar complications between the initial and subsequent retreatments. Fusiform morphology was the strongest predictor of retreatment failure.
      Citation: Stroke
      PubDate: 2021-10-12T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.033555
       
  • SLEAP SMART (Sleep Apnea Screening Using Mobile Ambulatory Recorders After
           TIA/Stroke): A Randomized Controlled Trial

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      Authors: Mark I. Boulos Maneesha Kamra David R. Colelli Nardin Kirolos David J. Gladstone Karl Boyle Arun Sundaram Julia J. Hopyan Richard H. Swartz Muhammad Mamdani Desmond Loong Wanrudee Isaranuwatchai Brian J. Murray Kevin E. Thorpe Hurvitz Brain Sciences Research Program; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.I.B., M.K., D.R.C., N.K., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.). Department of Medicine, Division of Neurology, University of Toronto, Ontario, Canada. (M.I.B., D.J.G., K.B., A.S., J.J.H., R.H.S., B.J.M.) Institute of Health Policy, Management Evaluation, University of Toronto, Ontario, Canada. (D.L., W.I.) Applied Health Research Centre & Dalla Lana School of Public Health, University of Toronto, Ontario, Canada. (K.E.T.) Sleep Laboratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.I.B., B.J.M.). Stroke Medicine, Beaumont Hospital, Dublin, Ireland (K.B.). Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Ontario, Canada (M.M., D.L., W.I).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Poststroke/transient ischemic attack obstructive sleep apnea (OSA) is prevalent, linked with numerous unfavorable health consequences, but remains underdiagnosed. Reasons include patient inconvenience and costs associated with use of in-laboratory polysomnography (iPSG), the current standard tool. Fortunately, home sleep apnea testing (HSAT) can accurately diagnose OSA and is potentially more convenient and cost-effective compared with iPSG. Our objective was to assess whether screening for OSA in patients with stroke/transient ischemic attack using HSAT, compared with standard of care using iPSG, increased diagnosis and treatment of OSA, improved clinical outcomes and patient experiences with sleep testing, and was a cost-effective approach.Methods:We consecutively recruited 250 patients who had sustained a stroke/transient ischemic attack within the past 6 months. Patients were randomized (1:1) to use of (1) HSAT versus (2) iPSG. Patients completed assessments and questionnaires at baseline and 6-month follow-up appointments. Patients diagnosed with OSA were offered continuous positive airway pressure. The primary outcome was compared between study arms via an intention-to-treat analysis.Results:At 6 months, 94 patients completed HSAT and 71 patients completed iPSG. A significantly greater proportion of patients in the HSAT arm were diagnosed with OSA (48.8% versus 35.2%,P=0.04) compared with the iPSG arm. Furthermore, patients assigned to HSAT, compared with iPSG, were more likely to be prescribed continuous positive airway pressure (40.0% versus 27.2%), report significantly reduced sleepiness, and a greater ability to perform daily activities. Moreover, a significantly greater proportion of patients reported a positive experience with sleep testing in the HSAT arm compared with the iPSG arm (89.4% versus 31.1%). Finally, a cost-effectiveness analysis revealed that HSAT was economically attractive for the detection of OSA compared with iPSG.Conclusions:In patients with stroke/transient ischemic attack, use of HSAT compared with iPSG increases the rate of OSA diagnosis and treatment, reduces daytime sleepiness, improves functional outcomes and experiences with sleep testing, and could be an economically attractive approach.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT02454023.
      Citation: Stroke
      PubDate: 2021-10-11T09:00:25Z
      DOI: 10.1161/STROKEAHA.120.033753
       
  • Treatment-Associated Stroke in Patients Undergoing Endovascular Therapy in
           the ARUBA Trial

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      Authors: Joshua D. Burks Evan M. Luther Vaidya Govindarajan Stephanie H. Chen Robert M. Starke Department of Neurosurgery; University of Miami, FL.
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Since the publication of ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformations), outcomes in treated and untreated patients with unruptured arteriovenous malformation have been thoroughly compared. However, no prior analysis of ARUBA patients has sought to identify risk factors for perioperative stroke. Improved understanding of risks within the ARUBA cohort will help clinicians apply the study’s findings in a broader context.Methods:The National Institute of Neurological Disorders and Stroke database was queried for all data relating to ARUBA patients, including demographics, interventions undertaken, and timing of stroke. Retrospective cohort analysis was performed with the primary outcome of perioperative stroke in patients who underwent endovascular intervention, and stroke risk was modeled with multivariate analysis.Results:A total of 64 ARUBA patients were included in the analysis. One hundred and fifty-ninth interventions were performed, and 26 (16%) procedures resulted in stroke within 48 hours of treatment. Posterior cerebral artery supply (adjusted odds ratio, 4.42 [95% CI, 1.23–15.9],P=0.02) and Spetzler-Martin grades 2 and 3 arteriovenous malformation (adjusted odds ratio, 7.76 [95% CI, 1.20–50.3],P=0.03; 9.64 [95% CI, 1.36–68.4],P=0.04, respectively) were associated with increased perioperative stroke risk in patients who underwent endovascular intervention. Patients treated in the United States or Germany had a significantly lower stroke risk than patients treated in other countries (adjusted odds ratio, 0.18 [95% CI, 0.04–0.82],P=0.02).Conclusions:Knowing patient and lesion characteristics that increase risk during endovascular treatment can better guide clinicians managing unruptured brain arteriovenous malformation. Our analysis suggests risk of perioperative stroke is dependent on Spetzler-Martin grade and posterior-circulation arterial supply. Differences in regional treatment paradigms may also affect stroke risk.
      Citation: Stroke
      PubDate: 2021-10-08T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.033743
       
  • Brain Network Dysfunction in Poststroke Delirium and Spatial Neglect: An
           fMRI Study

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      Authors: Olga Boukrina Mateusz Kowalczyk Yury Koush Yekyung Kong A.M. Barrett Center for Stroke Rehabilitation Research; Kessler Foundation, West Orange, NJ (O.B.). Department of Physical Medicine Neurocognitive Rehabilitation, Atlanta VA Medical Center, Decatur, GA (A.M.B.). Department of Neurology, Emory University School of Medicine, Atlanta, GA (A.M.B.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Delirium, an acute reduction in cognitive functioning, hinders stroke recovery and contributes to cognitive decline. Right-hemisphere stroke is linked with higher delirium incidence, likely, due to the prevalence of spatial neglect (SN), a right-brain disorder of spatial processing. This study tested if symptoms of delirium and SN after right-hemisphere stroke are associated with abnormal function of the right-dominant neural networks specialized for maintaining attention, orientation, and arousal.Methods:Twenty-nine participants with right-hemisphere ischemic stroke undergoing acute rehabilitation completed delirium and SN assessments and functional neuroimaging scans. Whole-brain functional connectivity of 4 right-hemisphere seed regions in the cortical-subcortical arousal and attention networks was assessed for its relationship to validated SN and delirium severity measures.Results:Of 29 patients, 6 (21%) met the diagnostic criteria for delirium and 16 (55%) for SN. Decreased connectivity of the right basal forebrain to brain stem and basal ganglia predicted more severe SN. Increased connectivity of the arousal and attention network regions with the parietal, frontal, and temporal structures in the unaffected hemisphere was also found in more severe delirium and SN.Conclusions:Delirium and SN are associated with decreased arousal network activity and an imbalance of cortico-subcortical hemispheric connectivity. Better understanding of neural correlates of poststroke delirium and SN will lead to improved neuroscience-based treatment development for these disorders.
      Citation: Stroke
      PubDate: 2021-10-08T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.035733
       
  • Association of ApoE Genotypes and Recovery From Intracerebral Hemorrhage
           in Very Low Birth Weight Infants

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      Authors: Alexander Humberg Mark Dzietko Sören Schulz Ursula Felderhoff-Müser Britta Hüning Anja Stein Mats I. Fortmann Janina Marissen Tanja K. Rausch Egbert Herting Christoph Härtel Wolfgang Göpel Department of Pediatrics; University Hospital of Schleswig-Holstein, Lübeck, Germany. (A.H., S.S., M.I.F., T.K.R., E.H., W.G.) Institute of Medical Biometry Statistics, University of Lübeck, University Hospital of Schleswig-Holstein, Lübeck, Germany. (T.K.R.) Department of Pediatrics I, University Duisburg-Essen, Germany (M.D., U.F-.M. B.H., A.S.). Department of Pediatrics, University Hospital of Würzburg, Germany (J.M., C.H.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Associations of APOE genotypes with intracerebral hemorrhage (ICH) in preterm infants were previously described. In adults, APOE-ε4 genotype has been proposed as susceptibility factor for impaired recovery after cerebral insult. We here aim to determine APOE genotype-specific neurological consequences of neonatal ICH at school age.Methods:In this multicenter observational cohort study, very low birth weight (<1500 g, <32 weeks gestational age) children were studied for cerebral palsy (CP) after ultrasound diagnosed ICH stratified by APOE genotype. Follow-up examination was done at the age of 5 to 6 years. Study personnel were blinded for perinatal information and complications. Participants were born between January 1, 2009 and December 31, 2013 and enrolled in the German Neonatal Network. Of 8022 infants primarily enrolled, 2467 children were invited for follow-up between January 1, 2014 and December 31, 2019. Univariate analyses and multivariate logistic regression models were used to assess the impact of APOE genotype (APOE-ε2, APOE-ε3, APOE-ε4) on CP after ICH.Results:Two thousand two hundred fifteen children participated at follow-up, including 363 children with ultrasound diagnosed neonatal ICH. In univariate analyses of children with a history of ICH, APOE-ε3 carriers had lower frequencies of CP (n=33/250; 13.2 [95% CI, 9.4%–17.8%]), as compared to APOE-ε2 (n=15/63; 23.8 [14.6%–35.3%],P=0.037) and –ε4 carriers (n=31/107; 29.0 [21.0%–38.0%],P<0.001), respectively. Regression models revealed an association of APOE-ε4 genotype and CP development (odds ratio, 2.77 [1.44–5.32],P=0.002) after ICH. Notably, at low-grade ICH (grade I) APOE-ε4 expression resulted in an increased rate of CP (n=6/39; 15.4 [6.7–29.0]) in comparison to APOE-ε3 (n=2/105; 1.9 [0.4%–6.0%],P=0.002).Conclusions:APOE-ε4 carriers have an increased risk for long-term motor deficits after ICH. We assume an effect even after low-grade neonatal ICH, but more data are needed to clarify this issue.
      Citation: Stroke
      PubDate: 2021-10-08T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.033432
       
  • Large-Scale Multivariate Analysis to Interrogate an Animal Model of
           Stroke: Novel Insights Into Poststroke Pathology

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      Authors: Shenpeng R. Zhang Hyun Ah Kim Hannah X. Chu Seyoung Lee Megan A. Evans Xia Li Henry Ma Grant R. Drummond Christopher G. Sobey Thanh G. Phan Department of Physiology; Anatomy Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia. (H.M., T.G.P.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Preclinical stroke studies endeavor to model the pathophysiology of clinical stroke, assessing a range of parameters of injury and impairment. However, poststroke pathology is complex and variable, and associations between diverse parameters may be difficult to identify within the usual small study designs that focus on infarct size.Methods:We have performed a retrospective large-scale big data analysis of records from 631 C57BL/6 mice of either sex in which the middle cerebral artery was occluded by 1 of 5 surgeons either transiently for 1 hour followed by 23-hour reperfusion (transient middle cerebral artery occlusion [MCAO]; n=435) or permanently for 24 hours without reperfusion (permanent MCAO; n=196). Analyses included a multivariate linear mixed model with random intercept for different surgeons as a random effect to reduce type I and type II errors and a generalized ordinal regression model for ordinal data when random effects are low.Results:Analyses indicated that brain edema volume was associated with infarct volume at 24 hours (β, 0.52 [95% CI, 0.45–0.59]) and was higher after permanent MCAO than after transient MCAO (P<0.05). A more severe clinical score was associated with a greater infarct volume but not with the animal’s age or edema volume. Further, a more severe clinical score was observed for a given brain infarct volume after transient MCAO versus permanent MCAO. Remarkably the animal’s age, which corresponded with the period of young adulthood (6–40 weeks; equivalent to ≈18–35 years in humans), was positively associated with severity of lung infection (β, 0.65 [95% CI, 0.42–0.88]) and negatively with spleen weight (β, −0.36 [95% CI, −0.63 to −0.09]).Conclusions:Large-scale analysis of preclinical stroke data can provide researchers in our field with insight into relationships between variables not possible if individual studies are analyzed in isolation and has identified hypotheses for future study.
      Citation: Stroke
      PubDate: 2021-10-08T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.036500
       
  • Minor Ischemic Stroke and a Smoldering Case of Giant-Cell Arteritis: A
           Case Report

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      Authors: Alexandru Dimancea Celine Guidoux Pierre Amarenco Neurology Department; Bichat Claude-Bernard Hospital, Paris.
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-10-08T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.035432
       
  • Keeping Up With the Medical Literature: Why, How, and When'

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      Authors: Joseph Kamtchum-Tatuene Joseline Guetsop Zafack The Neuroscience; Dentistry, University of Alberta, Edmonton, Canada (J.K.-T.). Public Health Agency of Canada (J.G.Z.).
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-10-08T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.036141
       
  • Translational Interdisciplinary Science—Immune Cell Niches: Possible
           Targets for Stroke Therapy'

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      Authors: Louise D. McCullough María A. Moro Department of Neurology; McGovern Medical School, The University of Texas Health Science Center, Memorial Hermann Hospital, Houston (L.D.M.). Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (M.A.M.). Unidad de Investigación Neurovascular, Departamento de Farmacología y Toxicología, Universidad Complutense de Madrid (UCM), Madrid, Spain (M.A.M.). Instituto Universitario de Investigación en Neuroquímica (IUIN), UCM, Madrid, Spain (M.A.M.). Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain (M.A.M.).
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-10-08T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.033969
       
  • No Racial Disparity in Outcome Measures After Endovascular Treatment for
           Stroke in the Elderly

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      Authors: Mahmoud H. Mohammaden Diogo C. Haussen Leonardo Pisani Alhamza R. Al-Bayati Nicolas Bianchi Bernardo Liberato Nirav Bhatt Michael R. Frankel Raul G. Nogueira Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M; D.C.H, L.P, A.R.A.-B, N.B, B.L, N.B, M.R.F, R.G.N.). Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M, D.C.H, L.P, A.R.A.-B, N.B, B.L, N.B, M.R.F, R.G.N.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Despite the lower rates of good outcomes and higher mortality in elderly patients, age does not modify the treatment effect of mechanical thrombectomy for large vessel occlusion strokes. We aimed to study whether racial background influences the outcome after mechanical thrombectomy in the elderly population.Methods:We reviewed a prospectively maintained database of patients with acute ischemic stroke treated with mechanical thrombectomy from October 2010 through June 2020 to identify all consecutive patients with age ≥80 years and anterior circulation large vessel occlusion strokes. The patients were categorized according to their race as Black and White. Univariable and multivariable analyses were performed to define the predictors of 90-day modified Rankin Scale and mortality in the overall population and in each race separately.Results:Among 2241 mechanical thrombectomy, a total of 344 patients (median [interquartile range]; age 85 [82–88] years, baseline National Institutes of Health Stroke Scale score of 19 [15–23], Alberta Stroke Program Early CT Score 9 [7–9], 69.5% females) were eligible for the analysis. White patients (n=251; 73%) had significantly lower median body mass index (25.37 versus 26.89,P=0.04) and less frequent hypertension (78.9% versus 90.3%,P=0.01) but more atrial fibrillation (64.5% versus 44.1%,P=0.001) compared with African Americans (n=93; 27%). Other clinical, imaging, and procedural characteristics were comparable between groups. The rates of symptomatic intracerebral hemorrhage, 90-day modified Rankin Scale score of 0 to 2, and mortality were comparable among both groups. On multivariable analysis, race was neither a predictor of 90-day modified Rankin Scale score of 0 to 2 (White race: odds ratio, 0.899 [95% CI, 0.409–1.974],P=0.79) nor 90-day mortality (White race: odds ratio, 1.368; [95% CI, 0.715–2.618],P=0.34).Conclusions:In elderly patients undergoing mechanical thrombectomy for acute ischemic stroke, there was no racial difference in terms of outcome.
      Citation: Stroke
      PubDate: 2021-10-06T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033537
       
  • Added Value of a Blinded Outcome Adjudication Committee in an Open-Label
           Randomized Stroke Trial

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      Authors: Nadinda A.M. van der Ende Bob Roozenbeek Olvert A. Berkhemer Peter J. Koudstaal Jelis Boiten Ewoud J. van Dijk Yvo B.W.E.M. Roos Robert J. van Oostenbrugge Charles B.L.M. Majoie Wim van Zwam Hester F. Lingsma Aad van der Lugt Diederik W.J. Dippel Department of Neurology; Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., B.R., O.A.B., P.J.K., D.W.J.D.) Department of Radiology Nuclear Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands. (W.v.Z.) , on behalf of the MR CLEAN Investigators Puck S.S. Fransen Debbie Beumer Lucie A. van den Berg Albert J. Yoo Wouter J. Schonewille Jan Albert Vos Paul J. Nederkoorn Marieke J.H. Wermer Marianne A.A. van Walderveen Julie Staals Jeannette Hofmeijer Jacques A. van Oostayen Geert J. Lycklama a Nijeholt Patrick A. Brouwer Bart J. Emmer Sebastiaan F. de Bruijn Lukas C. van Dijk L. Jaap Kappelle Rob H. Lo Joost de Vries Paul L.M. de Kort Willem Jan J. van Rooij Jan S.P. van den Berg Boudewijn A.A.M. van Hasselt Leo A.M. Aerden Rene J. Dallinga Marieke C. Visser Joseph C.J. Bot Patrick C. Vroomen Omid Eshghi Tobien H.C.M.L. Schreuder Roel J.J. Heijboer Koos Keizer Alexander V. Tielbeek Heleen M. den Hertog Dick G. Gerrits Renske M. van den Berg-Vos Giorgos B. Karas Ewout W. Steyerberg H. Zwenneke Flach Henk A. Marquering Marieke E.S. Sprengers Sjoerd F.M. Jenniskens Ludo F.M. Beenen Rene van den Berg
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Blinded outcome assessment in trials with prospective randomized open blinded end point design is challenging. Unblinding can result in misclassified outcomes and biased treatment effect estimates. An outcome adjudication committee assures blinded outcome assessment, but the added value for trials with prospective randomized open blinded end point design and subjective outcomes is unknown. We aimed to assess the degree of misclassification of modified Rankin Scale (mRS) scores by a central assessor and its impact on treatment effect estimates in a stroke trial with prospective randomized open blinded end point design.Methods:We used data from the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands). The primary outcome was the mRS at 90 days. Standardized, algorithm-based telephone interviews to assess the mRS were conducted from a central location by an experienced research nurse, unaware but not formally blinded to treatment allocation (central assessor). Masked reports of these interviews were adjudicated by a blinded outcome committee. Misclassification was defined as an incorrect classification of the mRS by the central assessor. The effect of endovascular treatment on the mRS was assessed with multivariable ordinal logistic regression.Results:In MR CLEAN, 53/500 (10.6%) of the mRS scores were misclassified. The degree and direction of misclassification did not differ between treatment arms (P=0.59). Benefit of endovascular treatment was shown on the mRS when scored by the central assessor (adjusted common odds ratio, 1.60 [95% CI, 1.16–2.21]) and the outcome adjudication committee (adjusted common odds ratio, 1.67 [95% CI, 1.21–2.20]).Conclusions:Misclassification by the central assessor was small, randomly distributed over treatment arms, and did not affect treatment effect estimates. This study suggests that the added value of a blinded outcome adjudication committee is limited in a stroke trial with prospective randomized open blinded end point design applying standardized, algorithm-based outcome assessment by a central assessor, who is unaware but not formally blinded to treatment allocation.REGISTRATION:URL:https://www.isrctn.com; Unique identifier: ISRCTN10888758.
      Citation: Stroke
      PubDate: 2021-10-05T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.035301
       
  • Impact of Delirium on Outcomes After Intracerebral Hemorrhage

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      Authors: Michael E. Reznik Seth A. Margolis Ali Mahta Linda C. Wendell Bradford B. Thompson Christoph Stretz James L. Rudolph Olga Boukrina A.M. Barrett Lori A. Daiello Richard N. Jones Karen L. Furie Department of Neurology; Brown University, Alpert Medical School, Providence, RI. (M.E.R., A.M., L.C.W., B.B.T., C.S., L.A.D., R.N.J., K.L.F.) Department of Neurosurgery, Brown University, Alpert Medical School, Providence, RI. (M.E.R., A.M., L.C.W., B.B.T.) Department of Psychiatry Neurocognitive Rehabilitation, Atlanta VA Health Care System, GA (A.M.B.). Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island (J.L.R.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Delirium portends worse outcomes after intracerebral hemorrhage (ICH), but it is unclear if symptom resolution or postacute care intensity may mitigate its impact. We aimed to explore differences in outcome associated with delirium resolution before hospital discharge, as well as the potential mediating role of postacute discharge site.Methods:We performed a single-center cohort study on consecutive ICH patients over 2 years. Delirium was diagnosed according to DSM-5 criteria and further classified as persistent or resolved based on delirium status at hospital discharge. We determined the impact of delirium on unfavorable 3-month outcome (modified Rankin Scale score, 4–6) using logistic regression models adjusted for established ICH predictors, then used mediation analysis to examine the indirect effect of delirium via postacute discharge site.Results:Of 590 patients (mean age 70.5±15.5 years, 52% male, 83% White), 59% (n=348) developed delirium during hospitalization. Older age and higher ICH severity were delirium risk factors, but only younger age predicted delirium resolution, which occurred in 75% (161/215) of ICH survivors who had delirium. Delirium was strongly associated with unfavorable outcome, but patients with persistent delirium fared worse (adjusted odds ratio [OR], 7.3 [95% CI, 3.3–16.3]) than those whose delirium resolved (adjusted OR, 3.1 [95% CI, 1.8–5.5]). Patients with delirium were less likely to be discharged to inpatient rehabilitation than skilled nursing facilities (adjusted OR, 0.31 [95% CI, 0.17–0.59]), and postacute care site partially mediated the relationship between delirium and functional outcome in ICH survivors, leading to a 25% reduction in the effect of delirium (without mediator: adjusted OR, 3.0 [95% CI, 1.7–5.6]; with mediator: adjusted OR, 2.3 [95% CI, 1.2–4.3]).Conclusions:Acute delirium resolves in most patients with ICH by hospital discharge, which was associated with better outcomes than in patients with persistent delirium. The impact of delirium on outcomes may be further mitigated by postacute rehabilitation.
      Citation: Stroke
      PubDate: 2021-10-05T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.034023
       
  • Complex Profiles of Cerebrovascular Disease Pathologies in the Aging Brain
           and Their Relationship With Cognitive Decline

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      Authors: Melissa Lamar Sue Leurgans Alifiya Kapasi Lisa L. Barnes Patricia A. Boyle David A. Bennett Konstantinos Arfanakis Julie A. Schneider Rush Alzheimer’s Disease Center; Rush University Medical Center, Chicago, IL. (M.L., S.L., A.K., L.L.B., P.A.B., D.A.B., K.A., J.A.S.) Department of Psychiatry Nuclear Medicine, Rush University Medical Center, Chicago, IL. (K.A.) Department of Biomedical Engineering, Illinois Institute of Technology, Chicago (K.A.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Cerebrovascular disease (CVD) pathologies including vessel disease (atherosclerosis, arteriolosclerosis, and cerebral amyloid angiopathy) and tissue injury (macroinfarcts and microinfarcts) each contribute to Alzheimer and other forms of dementia. CVD is often a complex mix of neuropathologies, with little known about the frequencies of differing combinations or their associations with cognition.Methods:We investigated 32 possible CVD combinations (3 types of vessel disease and 2 types of tissue injury) using autopsy data from 1474 decedents (≈88 years at death; 65% female) of Rush Alzheimer’s Disease Center studies. We determined frequencies of all 32 CVD combinations and their relationships with global and domain-specific cognitive decline using mixed-effect models adjusted for demographics, neuropathologies, time before death, and interactions of these variables with time.Results:Of the 1184 decedents with CVD neuropathology (80% of the total sample), 37% had a single CVD (67–148 decedents/group) while 63% had mixed CVD profiles (11–54 decedents/group). When considered as 2 distinct groups, the mixed CVD profile group (but not the single CVD profile group) showed a faster cognitive decline across all domains assessed compared with decedents without CVD neuropathology. Most mixed CVD profiles, especially those involving both atherosclerosis and arteriolosclerosis, showed faster cognitive decline than any single CVD profile considered alone; specific mixed CVD profiles differentially associated with individual cognitive domains.Conclusions:Mixed CVD, more common than single CVD, is associated with cognitive decline, and distinct mixed CVD profiles show domain-specific associations with cognitive decline. CVD is not monolithic but consists of heterogenous person-specific combinations with distinct contributions to cognitive decline.
      Citation: Stroke
      PubDate: 2021-10-04T09:00:06Z
      DOI: 10.1161/STROKEAHA.121.034814
       
  • A Robust Deep Learning Segmentation Method for Hematoma Volumetric
           Detection in Intracerebral Hemorrhage

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      Authors: Nannan Yu He Yu Haonan Li Nannan Ma Chunai Hu Jia Wang Department of Artificial Intelligence; School of Electrical Engineering Automation, Jiangsu Normal University, Xuzhou, China (N.Y., H.Y.). Department of Biotechnology, College of Basic Medical Sciences, Dalian Medical University, China (H.L., J.W.). Radiology Department, Xuzhou Central Hospital, China (N.M., C.H.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Hematoma volume (HV) is a significant diagnosis for determining the clinical stage and therapeutic approach for intracerebral hemorrhage (ICH). The aim of this study is to develop a robust deep learning segmentation method for the fast and accurate HV analysis using computed tomography.Methods:A novel dimension reduction UNet (DR-UNet) model was developed for computed tomography image segmentation and HV measurement. Two data sets, 512 ICH patients with 12 568 computed tomography slices in the retrospective data set and 50 ICH patients with 1257 slices in the prospective data set, were used for network training, validation, and internal and external testing. Moreover, 13 irregular hematoma cases, 11 subdural and epidural hematoma cases, and 50 different HV cases into 3 groups (<30, 30–60, and >60 mL) were selected to further evaluate the robustness of DR-UNet. The image segmentation performance of DR-UNet was compared with those of UNet, the fuzzy clustering method, and the active contour method. The HV measurement performance was compared using DR-UNet, UNet, and the Coniglobus formula method.Results:Using DR-UNet, the segmentation model achieved a performance similar to that of expert clinicians in 2 independent test data sets containing internal testing data (Dice of 0.861±0.139) and external testing data (Dice of 0.874±0.130). The HV measurement derived from DR-UNet was strongly correlated with that from manual segmentation (R2=0.9979;P<0.0001). In the irregularly shaped hematoma group and the subdural and epidural hematoma group, DR-UNet was more robust than UNet in both hematoma segmentation and HV measurement. There is no statistical significance in segmentation accuracy among 3 different HV groups.Conclusions:DR-UNet can segment hematomas from the computed tomography scans of ICH patients and quantify the HV with better accuracy and greater efficiency than the main existing methods and with similar performance to expert clinicians. Due to robust performance and stable segmentation on different ICHs, DR-UNet could facilitate the development of deep learning systems for a variety of clinical applications.
      Citation: Stroke
      PubDate: 2021-10-04T09:00:06Z
      DOI: 10.1161/STROKEAHA.120.032243
       
  • Ischemic Stroke in Patients With Hypertrophic Cardiomyopathy According to
           Presence or Absence of Atrial Fibrillation

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      Authors: Laurent Fauchier Arnaud Bisson Alexandre Bodin Julien Herbert Pascal Spiesser Bertrand Pierre Nicolas Clementy Anne Bernard Dominique Babuty Gregory Y.H. Lip Service de Cardiologie; Centre Hospitalier Universitaire Trousseau et EA7505, Faculté de Médecine, Université François Rabelais, Tours, France. (L.F., A. Bisson, A. Bodin, J.H., P.S., B.P., N.C., A. Bernard, D.B.) Service d’information médicale, d’épidémiologie et d’économie de la santé, Centre Hospitalier Universitaire Trousseau et EA7505, Faculté de Médecine, Université François Rabelais, Tours, France. (J.H.) Liverpool Centre for Cardiovascular Science, University of Liverpool Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark (G.Y.H.L.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Patients with hypertrophic cardiomyopathy (HCM) have high risk of ischemic stroke (IS), especially if atrial fibrillation (AF) is present. Improvements in risk stratification are needed to help identify those patients with HCM at higher risk of stroke, whether AF is present or not.Methods:This French longitudinal cohort study from the database covering hospital care from 2010 to 2019 analyzed adults hospitalized with isolated HCM. A logistic regression model was used to construct a French HCM score, which was compared with the HCM Risk-CVA and CHA2DS2-VASc scores using c-indexes and calibration analysis.Results:In 32 206 patients with isolated HCM, 12 498 (38.8%) had AF, and 2489 (7.7%) sustained an IS during follow-up. AF in patients with HCM was independently associated with a higher risk for death (hazard ratio, 1.129 [95% CI, 1.088–1.172]), cardiovascular death (hazard ratio, 1.254 [95% CI, 1.177–1.337]), IS (hazard ratio, 1.210 [95% CI, 1.111–1.317]), and other major cardiovascular events. Independent predictors of IS in HCM were older age, heart failure, AF, prior IS, smoking and poor nutrition (allP<0.05). For the HCM Risk-CVA score, CHA2DS2-VASc score and a French HCM score, all c-indexes were 0.65 to 0.70, with good calibration. Among patients with AF, the CHA2DS2-VASc score had marginal improvement over the HCM Risk-CVA score but was less predictive compared with the French HCM score (P=0.001). In patients without AF, both HCM Risk-CVA score and the French HCM score had significantly better prediction compared with CHA2DS2-VASc (bothP<0.0001). Decision curve analysis demonstrated that the French HCM score had the best clinical usefulness of the 3 tested risk scores.Conclusions:Patients with HCM have a high prevalence of AF and a significant risk of IS, and the presence of AF in patients with HCM was independently associated with worse outcomes. A simple French HCM score shows good prediction of IS in patients with HCM and clinical usefulness, with good calibration.
      Citation: Stroke
      PubDate: 2021-10-04T09:00:06Z
      DOI: 10.1161/STROKEAHA.121.034213
       
  • Fast Outcome Categorization of the Upper Limb After Stroke

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      Authors: Harry T. Jordan Joia Che Winston D. Byblow Cathy M. Stinear Clinical Neuroscience Laboratory, Department of Medicine, The University of Auckland, New Zealand (H.T.J; J.C, C.M.S.). School of Medicine, Monash University, Melbourne, Australia (J.C.). Movement Neuroscience Laboratory, Department of Exercise Sciences, The University of Auckland, New Zealand. (W.D.B.) Centre for Brain Research, The University of Auckland, New Zealand. (W.D.B, C.M.S.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The ARAT (Action Research Arm Test) has been used to classify upper limb motor outcome after stroke in 1 of 3, 4, or 5 categories. The coronavirus disease 2019 (COVID-19) pandemic has encouraged the development of assessments that can be performed quickly and remotely. The aim of this study was to derive and internally validate decision trees for categorizing upper limb motor outcomes at the late subacute and chronic stages of stroke using a subset of ARAT tasks.Methods:This study retrospectively analyzed ARAT scores obtained in-person at 3 months poststroke from 333 patients. In-person ARAT scores were used to categorize patients’ 3-month upper limb outcome using classification systems with 3, 4, and 5 outcome categories. Individual task scores from in-person assessments were then used in classification and regression tree analyses to determine subsets of tasks that could accurately categorize upper limb outcome for each of the 3 classification systems. The decision trees developed using 3-month ARAT data were also applied to in-person ARAT data obtained from 157 patients at 6 months poststroke.Results:The classification and regression tree analyses produced decision trees requiring 2 to 4 ARAT tasks. The overall accuracy of the cross-validated decision trees ranged from 87.7% (SE, 1.0%) to 96.7% (SE, 2.0%). Accuracy was highest when classifying patients into one of 3 outcome categories and lowest for 5 categories. The decision trees are referred to as FOCUS (Fast Outcome Categorization of the Upper Limb After Stroke) assessments and they remained accurate for 6-month poststroke ARAT scores (overall accuracy range 83.4%–91.7%).Conclusions:A subset of ARAT tasks can accurately categorize upper limb motor outcomes after stroke. Future studies could investigate the feasibility and accuracy of categorizing outcomes using the FOCUS assessments remotely via video call.
      Citation: Stroke
      PubDate: 2021-10-04T09:00:06Z
      DOI: 10.1161/STROKEAHA.121.035170
       
  • Timing and Dose of Upper Limb Motor Intervention After Stroke: A
           Systematic Review

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      Authors: Kathryn S. Hayward Sharon F. Kramer Emily J. Dalton Gemma R. Hughes Amy Brodtmann Leonid Churilov Geoffrey Cloud Dale Corbett Laura Jolliffe Tina Kaffenberger Venesha Rethnam Vincent Thijs Nick Ward Natasha Lannin Julie Bernhardt Departments of Physiotherapy; Neurosurgery, London, United Kingdom (N.W.).
      Abstract: Stroke, Ahead of Print.
      This systematic review aimed to investigate timing, dose, and efficacy of upper limb intervention during the first 6 months poststroke. Three online databases were searched up to July 2020. Titles/abstracts/full-text were reviewed independently by 2 authors. Randomized and nonrandomized studies that enrolled people within the first 6 months poststroke, aimed to improve upper limb recovery, and completed preintervention and postintervention assessments were included. Risk of bias was assessed using Cochrane reporting tools. Studies were examined by timing (recovery epoch), dose, and intervention type. Two hundred and sixty-one studies were included, representing 228 (n=9704 participants) unique data sets. The number of studies completed increased from one (n=37 participants) between 1980 and 1984 to 91 (n=4417 participants) between 2015 and 2019. Timing of intervention start has not changed (median 38 days, interquartile range [IQR], 22–66) and study sample size remains small (median n=30, IQR 20–48). Most studies were rated high risk of bias (62%). Study participants were enrolled at different recovery epochs: 1 hyperacute (<24 hours), 13 acute (1–7 days), 176 early subacute (8–90 days), 34 late subacute (91–180 days), and 4 were unable to be classified to an epoch. For both the intervention and control groups, the median dose was 45 (IQR, 600–1430) min/session, 1 (IQR, 1–1) session/d, 5 (IQR, 5–5) d/wk for 4 (IQR, 3–5) weeks. The most common interventions tested were electromechanical (n=55 studies), electrical stimulation (n=38 studies), and constraint-induced movement (n=28 studies) therapies. Despite a large and growing body of research, intervention dose and sample size of included studies were often too small to detect clinically important effects. Furthermore, interventions remain focused on subacute stroke recovery with little change in recent decades. A united research agenda that establishes a clear biological understanding of timing, dose, and intervention type is needed to progress stroke recovery research. Prospective Register of Systematic Reviews ID: CRD42018019367/CRD42018111629.
      Citation: Stroke
      PubDate: 2021-10-04T09:00:06Z
      DOI: 10.1161/STROKEAHA.121.034348
       
  • Risk Factor Characterization of Ischemic Stroke Subtypes Among West
           Africans

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      Authors: Fred S. Sarfo Bruce Ovbiagele Onoja Akpa Albert Akpalu Kolawole Wahab Reginald Obiako Morenikeji Komolafe Lukman Owolabi Godwin Ogbole Benedict Calys-Tagoe Adekunle Fakunle Taofeek Sanni Gebregziabher Mulugeta Salaam Abdul Adeseye A. Akintunde Samuel Olowookere Ezinne O. Uvere Philip Ibinaiye Joshua Akinyemi Kelechukwu Uwanuruochi Balogun Olayemi Olufemi A. Odunlami Esther Abunimye Oyedunni Arulogun Suleiman Y. Isah Sani A. Abubakar Adebayo Oladimeji Philip Adebayo Vincent Shidali Innocent I. Chukwuonye Josephine Akpalu Moyinoluwalogo M. Tito-Ilori Osahon J. Asowata Emmanuel O. Sanya Ganiyu Amusa Ugochukwu Onyeonoro James A. Ogunmodede Abdullateef G. Sule Cynthia Akisanya Yaw Mensah Olalekan I. Oyinloye Lambert Appiah Atinuke M. Agunloye Godwin O. Osaigbovo Eunice Olabinri Philip M. Kolo Obiora Okeke Abiodun M. Adeoye Olabamiji Ajose Carolyn Jenkins Daniel T. Lackland Adedeji A. Egberongbe Olaleye Adeniji Osimhiarherhuo Ohifemen Adeleye Hemant K. Tiwari Donna Arnett Ruth Y. Laryea Taiwo Olunuga Kazeem S. Akinwande Lucius Imoh Okechukwu S. Ogah Ezinne S. Melikam Adeyemo Adebolaji Wisdom Oguike Olumayowa Ogunronbi Wasiu Adeniyi Obiabo Y. Olugbo Abiodun H. Bello Kenneth A. Ohagwu Luqman Ogunjimi Francis Agyekum Henry Iheonye Julius Adesina Samuel Diala Hamisu A. Dambatta Joyce Ikubor Arti Singh Sheila Adamu Vida Obese Nathaniel Adusei Dorcas Owusu Michael Ampofo Raelle Tagge Richard Efidi Bimbo Fawale Joseph Yaria Rufus Akinyemi Mayowa Owolabi Department of Medicine; Kwame Nkrumah University of Science Therapeutics, Olabisi Onabanjo University. Abeokuta, Nigeria (L.O.). Greater Accra Regional Hospital, Accra, Ghana (F.A.). Federal Medical Centre, Lokoja, Kogi state, Nigeria (H.I.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:To identify the qualitative and quantitative contributions of conventional risk factors for occurrence of ischemic stroke and its key pathophysiologic subtypes among West Africans.Methods:The SIREN (Stroke Investigative Research and Educational Network) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with ischemic stroke who were etiologically subtyped using the A-S-C-O-D classification into atherosclerosis, small-vessel occlusion, cardiac pathology, other causes, and dissection. Controls were age- and gender-matched stroke-free adults. Detailed evaluations for vascular, lifestyle, and psychosocial factors were performed. We used conditional logistic regression to estimate adjusted odds ratios with 95% CI.Results:There were 2431 ischemic stroke case and stroke-free control pairs with respective mean ages of 62.2±14.0 versus 60.9±13.7 years. There were 1024 (42.1%) small vessel occlusions, 427 (17.6%) large-artery atherosclerosis, 258 (10.6%) cardio-embolic, 3 (0.1%) carotid dissections, and 719 (29.6%) undetermined/other causes. The adjusted odds ratio (95% CI) for the 8 dominant risk factors for ischemic stroke were hypertension, 10.34 (6.91–15.45); dyslipidemia, 5.16 (3.78–7.03); diabetes, 3.44 (2.60–4.56); low green vegetable consumption, 1.89 (1.45–2.46); red meat consumption, 1.89 (1.45–2.46); cardiac disease, 1.88 (1.22–2.90); monthly income $100 or more, 1.72 (1.24–2.39); and psychosocial stress, 1.62 (1.18–2.21). Hypertension, dyslipidemia, diabetes were confluent factors shared by small-vessel, large-vessel and cardio-embolic subtypes. Stroke cases and stroke-free controls had a mean of 5.3±1.5 versus 3.2±1.0 adverse cardio-metabolic risk factors respectively (P<0.0001).Conclusions:Traditional vascular risk factors demonstrate important differential effect sizes with pathophysiologic, clinical and preventative implications on the occurrence of ischemic stroke among indigenous West Africans.
      Citation: Stroke
      PubDate: 2021-09-30T09:00:16Z
      DOI: 10.1161/STROKEAHA.120.032072
       
  • Detection of Advanced Lesions of Atherosclerosis in Carotid Arteries Using
           3-Dimensional Motion-Sensitized Driven-Equilibrium Prepared Rapid Gradient
           Echo (3D-MERGE) Magnetic Resonance Imaging as a Screening Tool

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      Authors: Duygu Baylam Geleri Hiroko Watase Baocheng Chu Li Chen Huilin Zhao Xihai Zhao Thomas S Hatsukami Chun Yuan Department of Radiology; University of Washington, Seattle, WA. (D.B.G, B.C., C.Y.) Department of Electrical Computer Engineering, University of Washington, Seattle, WA. (L.C.) BioMolecular Imaging Center, University of Washington, Seattle, WA. (B.C., C.Y.) Department of Surgery, University of Washington, Seattle, WA. (H.W., T.S.H.) Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University Shanghai, China (H.Z.). Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China (X.Z.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Two-dimensional high-resolution multicontrast magnetic resonance imaging (2D-MC MRI) is currently the most reliable and reproducible noninvasive carotid vessel wall imaging technique. However, the long scan time required for 2D-MC MRI restricts its practical clinical application. Alternatively, 3-dimensional motion-sensitized driven-equilibrium prepared rapid gradient echo (3D-MERGE) vessel wall MRI can provide high isotropic resolution with extensive coverage in two minutes. In this study, we sought to prove that 3D-MERGE alone can serve as a screening tool to identify advanced carotid lesions.Methods:Two hundred twenty-seven subjects suspected of recent ischemic stroke or transient ischemic attack were imaged using 2D-MC MRI with an imaging time of 30 minutes, then with 3D-MERGE with an imaging time of 2 minutes, on 3T-MRI scanners. Two experienced reviewers interpreted plaque components using 2D-MC MRI as the reference standard and categorized plaques using a modified American Heart Association lesion classification for MRI. Plaques of American Heart Association type IV and above were classified as advanced. Arteries of American Heart Association types I to II and III were categorized as normal or with early lesions, respectively. One radiologist independently reviewed only 3D-MERGE and labeled the plaques as advanced if they had a wall thickness of >2 mm with high or low signal intensity compared with the adjacent sternocleidomastoid muscle. Sensitivity, specificity, and accuracy for 3D-MERGE were calculated.Results:Four hundred forty-nine arteries from 227 participants (mean age 61.2 years old, 64% male) were included in the analysis. Sensitivity, specificity, and accuracy for identification of advanced lesions on 3D-MERGE were 95.0% (95% CI, 91.8–97.2), 86.9% (95% CI, 81.4–92.0), 93.8% (95% CI, 91.1–95.8), respectively.Conclusions:3D-MERGE can accurately identify advanced carotid atherosclerotic plaques in patients suspected of stroke or transient ischemic attack. It has a more extensive coverage and higher sensitivity and specificity for advanced plaque detection with a much shorter acquisition time than 2D-MC MRI.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT02017756.
      Citation: Stroke
      PubDate: 2021-09-30T09:00:16Z
      DOI: 10.1161/STROKEAHA.120.032505
       
  • CCL2 (C-C Motif Chemokine Ligand 2) Biomarker Responses in Central Versus
           Peripheral Compartments After Focal Cerebral Ischemia

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      Authors: Jingfei Shi Wenlu Li Fang Zhang Ji Hyun Park Hong An Shuzhen Guo Yunxia Duan Di Wu Kazuhide Hayakawa Eng H. Lo Xunming Ji Cerebrovascular; Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (J.S., W.L., F.Z., J.H.P., H.A., S.G., D.W., K.H., E.H.L.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Inflammatory mediators in blood have been proposed as potential biomarkers in stroke. However, a direct relationship between these circulating factors and brain-specific ischemic injury remains to be fully defined.Methods:An unbiased screen in a nonhuman primate model of stroke was used to find out the most responsive circulating biomarker flowing ischemic stroke. Then this phenomenon was checked in human beings and mice. Finally, we observed the temporospatial responsive characteristics of this biomarker after ischemic brain injury in mice to evaluate the direct relationship between this circulating factor and central nervous system–specific ischemic injury.Results:In a nonhuman primate model, an unbiased screen revealed CCL2 (C-C motif chemokine ligand 2) as a major response factor in plasma after stroke. In mouse models of focal cerebral ischemia, plasma levels of CCL2 showed a transient response, that is, rapidly elevated by 2 to 3 hours postischemia but then renormalized back to baseline levels by 24 hours. However, a different CCL2 temporal profile was observed in whole brain homogenate, cerebrospinal fluid, and isolated brain microvessels, with a progressive increase over 24 hours, demonstrating a mismatch between brain versus plasma responses. In contrast to the lack of correlation with central nervous system responses, 2 peripheral compartments showed transient profiles that matched circulating plasma signatures. CCL2 protein in lymph nodes and adipose tissue was significantly increased at 2 hours and renormalized by 24 hours.Conclusions:These findings may provide a cautionary tale for biomarker pursuits in plasma. Besides a direct central nervous system response, peripheral organs may also contribute to blood signatures in complex and indirect ways.
      Citation: Stroke
      PubDate: 2021-09-30T09:00:16Z
      DOI: 10.1161/STROKEAHA.120.032782
       
  • Prediction of Stroke Infarct Growth Rates by Baseline Perfusion Imaging

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      Authors: Anke Wouters David Robben Soren Christensen Henk A. Marquering Yvo B.W.E.M. Roos Robert J. van Oostenbrugge Wim H. van Zwam Diederik W.J. Dippel Charles B.L.M. Majoie Wouter J. Schonewille Aad van der Lugt Maarten Lansberg Gregory W. Albers Paul Suetens Robin Lemmens Department of Neurology; University Hospitals Leuven, Belgium (A.W., R.L.). Department of Neurosciences, Experimental Neurology, KU Leuven – University of Leuven, Belgium (A.W., R.L.). Center for Brain & Disease Research, Laboratory of Neurobiology, VIB, Leuven, Belgium (A.W., R.L.). Department of Neurology, Academic Medical Center, the Netherlands (A.W., Y.B.W.E.M.R.). Medical Imaging Research Center (MIRC), KU Leuven, Belgium (D.R., P.S.). Medical Image Computing (MIC), ESAT-PSI, Department of Electrical Engineering, KU Leuven, Belgium (D.R., P.S.). Icometrix, Leuven, Belgium (D.R.). GrayNumber Analytics, Lomma, Sweden (S.C.). Department of Radiology Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands (A.v.d.L.). Stanford Stroke Center, Stanford University, CA (M.L., G.W.A.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Computed tomography perfusion imaging allows estimation of tissue status in patients with acute ischemic stroke. We aimed to improve prediction of the final infarct and individual infarct growth rates using a deep learning approach.Methods:We trained a deep neural network to predict the final infarct volume in patients with acute stroke presenting with large vessel occlusions based on the native computed tomography perfusion images, time to reperfusion and reperfusion status in a derivation cohort (MR CLEAN trial [Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands]). The model was internally validated in a 5-fold cross-validation and externally in an independent dataset (CRISP study [CT Perfusion to Predict Response to Recanalization in Ischemic Stroke Project]). We calculated the mean absolute difference between the predictions of the deep learning model and the final infarct volume versus the mean absolute difference between computed tomography perfusion imaging processing by RAPID software (iSchemaView, Menlo Park, CA) and the final infarct volume. Next, we determined infarct growth rates for every patient.Results:We included 127 patients from the MR CLEAN (derivation) and 101 patients of the CRISP study (validation). The deep learning model improved final infarct volume prediction compared with the RAPID software in both the derivation, mean absolute difference 34.5 versus 52.4 mL, and validation cohort, 41.2 versus 52.4 mL (P<0.01). We obtained individual infarct growth rates enabling the estimation of final infarct volume based on time and grade of reperfusion.Conclusions:We validated a deep learning-based method which improved final infarct volume estimations compared with classic computed tomography perfusion imaging processing. In addition, the deep learning model predicted individual infarct growth rates which could enable the introduction of tissue clocks during the management of acute stroke.
      Citation: Stroke
      PubDate: 2021-09-30T09:00:16Z
      DOI: 10.1161/STROKEAHA.121.034444
       
  • Cerebral Small Vessel Disease and Depression Among Intracerebral
           Hemorrhage Survivors

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      Authors: Juan Pablo Castello Marco Pasi Patryk Kubiszewski Jessica R. Abramson Andreas Charidimou Christina Kourkoulis Zora DiPucchio Kristin Schwab Christopher D. Anderson M. Edip Gurol Steven M. Greenberg Jonathan Rosand Anand Viswanathan Alessandro Biffi Department of Neurology; Massachusetts General Hospital, Boston. (J.P.C., M.P., P.K., J.R.A., A.C., C.K., Z.D., K.S., C.D.A., M.E.G., S.M.G., J.R., A.V., A.B.) Hemorrhagic Stroke Research Program, Massachusetts General Hospital, Boston. (J.P.C., P.K., J.R.A., A.C., C.K., Z.D., K.S., C.D.A., M.E.G., S.M.G., J.R., A.V., A.B.) Henry Cognition, France (M.P.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Intracerebral hemorrhage (ICH) is an acute manifestation of cerebral small vessel disease (CSVD), usually cerebral amyloid angiopathy or hypertensive arteriopathy. CSVD-related imaging findings are associated with increased depression incidence in the general population. Neuroimaging may, therefore, provide insight on depression risk among ICH survivors. We sought to determine whether CSVD CT and magnetic resonance imaging markers are associated with depression risk (before and after ICH), depression remission, and effectiveness of antidepressant treatment.Methods:We analyzed data from the single-center longitudinal ICH study conducted at Massachusetts General Hospital. Participants underwent CT and magnetic resonance imaging imaging and were followed longitudinally. We extracted information for neuroimaging markers of CSVD subtype and severity. Outcomes of interest included pre-ICH depression, new-onset depression after ICH, resolution of depressive symptoms, and response to antidepressant treatment.Results:We followed 612 ICH survivors for a median of 47.2 months. Multiple CSVD-related markers were associated with depression risk. Survivors of cerebral amyloid angiopathy-related lobar ICH were more likely to be diagnosed with depression before ICH (odds ratio, 1.68 [95% CI, 1.14–2.48]) and after ICH (sub-hazard ratio, 1.52 [95% CI, 1.12–2.07]), less likely to achieve remission of depressive symptoms (sub-hazard ratio, 0.69 [95% CI, 0.51–0.94]), and to benefit from antidepressant therapy (P=0.041). Cerebral amyloid angiopathy disease burden on magnetic resonance imaging was associated with depression incidence and treatment resistance (interactionP=0.037), whereas hypertensive arteriopathy disease burden was only associated with depression incidence after ICH.Conclusions:CSVD severity is associated with depression diagnosis, both before and after ICH. Cerebral amyloid angiopathy-related ICH survivors are more likely to experience depression (both before and after ICH) than patients diagnosed with hypertensive arteriopathy-related ICH, and more likely to report persistent depressive symptoms and display resistance to antidepressant treatment.
      Citation: Stroke
      PubDate: 2021-09-30T09:00:16Z
      DOI: 10.1161/STROKEAHA.121.035488
       
  • Use of the Estimand Framework to Manage the Disruptive Effects of COVID-19
           on Stroke Clinical Trials

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      Authors: Nawaf Yassi Kathryn S. Hayward Bruce C.V. Campbell Leonid Churilov Departments of Medicine; Mental Health, Parkville, Australia (K.S.H., B.C.V.C.).
      Abstract: Stroke, Ahead of Print.
      The coronavirus disease 2019 (COVID-19) pandemic has presented unique challenges to stroke care and research internationally. In particular, clinical trials in stroke are vulnerable to the impacts of the pandemic at multiple stages, including design, recruitment, intervention, follow-up, and interpretation of outcomes. A carefully considered approach is required to ensure the appropriate conduct of stroke trials during the pandemic and to maintain patient and participant safety. This has been recently addressed by the International Council for Harmonisation which, in November 2019, released an addendum to the Statistical Principles for Clinical Trials guidelines entitled Estimands and Sensitivity Analysis in Clinical Trials. In this article, we present the International Council for Harmonisation estimand framework for the design and conduct of clinical trials, with a specific focus on its application to stroke clinical trials. This framework aims to align the clinical and scientific objectives of a trial with its design and end points. It also encourages the prospective consideration of potential postrandomization intercurrent events which may occur during a trial and either impact the ability to measure an end point or its interpretation. We describe the different categories of such events and the proposed strategies for dealing with them, specifically focusing on the COVID-19 pandemic as a source of intercurrent events. We also describe potential practical impacts posed by the COVID-19 pandemic on trials, health systems, study groups, and participants, all of which should be carefully reviewed by investigators to ensure an adequate practical and statistical strategy is in place to protect trial integrity. We provide examples of the implementation of the estimand framework within hypothetical stroke trials in intracerebral hemorrhage and stroke recovery. While the focus of this article is on COVID-19 impacts, the strategies and principles proposed are well suited for other potential events or issues, which may impact clinical trials in the field of stroke.
      Citation: Stroke
      PubDate: 2021-09-30T09:00:16Z
      DOI: 10.1161/STROKEAHA.121.036537
       
  • Association Between Enlarged Perivascular Spaces and White Matter
           Microstructure

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      Authors: Zi-Yue Liu Si-Yu Chen Mei-Jun Shu Fei-Fei Zhai Fei Han Li-Xin Zhou Jun Ni Ming Yao Shu-Yang Zhang Zheng-Yu Jin Li-Ying Cui Yi-Cheng Zhu Department of Neurology; State Key Laboratory of Complex Severe Peking Union Medical College, China. (Z.-Y.J.) Department of Radiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, China (S.-Y.C.).
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-09-30T09:00:16Z
      DOI: 10.1161/STROKEAHA.121.036077
       
  • The Stockholm Stroke Triage Project: Outcomes of Endovascular Thrombectomy
           Before and After Triage Implementation

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      Authors: Boris Keselman Annika Berglund Niaz Ahmed Matteo Bottai Mia von Euler Staffan Holmin Ann-Charlotte Laska Jan M. Mathé Christina Sjöstrand Einar E. Eriksson Michael V. Mazya Department of Neurology; Karolinska University Hospital, Stockholm, Sweden. (B.K., A.B., N.A., C.S., E.E.E., M.V.M.) Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden. (S.H.) Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. (B.K., A.B., N.A., S.H., J.M.M., C.S., E.E.E., M.V.M.) Unit of Biostatistics, Karolinska Institutet, Stockholm, Sweden. IMM (M.B.) Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden. (A.-C.L.) Department of Clinical Science Education, Karolinska Institutet Stroke Research Network at Södersjukhuset, Stockholm, Sweden (M.v.E.). School of Medicine, Örebro University, Sweden (M.v.E.). Department of Neurology, Capio St Göran’s Hospital, Stockholm, Sweden (J.M.M.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The Stockholm Stroke Triage System (SSTS) is a prehospital algorithm for detection of endovascular thrombectomy (EVT)-eligible patients, combining symptom severity assessment and ambulance-to-hospital teleconsultation, leading to a decision on primary stroke center bypass. In the Stockholm Region (6 primary stroke centers, 1 EVT center), SSTS implementation in October 2017 reduced onset-to-EVT time by 69 minutes. We compared clinical outcomes before and after implementation of SSTS in an observational study.Methods:We prospectively recruited patients transported by Code Stroke ambulance within the Stockholm region under the SSTS, treated with EVT during October 2017 to October 2019, and compared to EVT patients from 2 previous years. Outcomes: shift in modified Rankin Scale (mRS) scores, mRS score 0 to 1, mRS score 0 to 2, and death (all 3 months), National Institutes of Health Stroke Scale (NIHSS) score change 24-hour post-EVT, recanalization (Thrombolysis in Cerebral Infarction 2b-3), and symptomatic intracranial hemorrhage. mRS outcomes were adjusted for age and baseline NIHSS.Results:Patients with EVT in the SSTS group (n=244) were older and had higher baseline NIHSS versus historical controls (n=187): median age 74 (interquartile range, 63–81) versus 71 (61–78); NIHSS score 17 (11.5–21) versus 15 (10–20). During SSTS, median onset-to-puncture time was 136 versus 205 minutes (P<0.001). Adjusted common odds ratio for lower mRS in SSTS patients was 1.7 (95% CI, 1.2–2.3) versus controls. During SSTS, 83/240 (34.6%) versus 44/186 (23.7%) reached 3-month mRS score 0 to 1 (P=0.014), adjusted common odds ratio 2.3 (95% CI, 1.4–3.6). Median NIHSS change 24-hour post-EVT was 6 versus 4 (P=0.005). Differences in Thrombolysis in Cerebral Infarction, symptomatic intracranial hemorrhage, and death were nonsignificant.Conclusions:With an onset to arterial puncture time reduction by 69 minutes, outcomes in thrombectomy-treated patients improved significantly after region-wide large artery occlusion triage system implementation. These results warrant replication studies in other geographic and organizational circumstances.
      Citation: Stroke
      PubDate: 2021-09-29T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034195
       
  • Stroke Patients With Faster Core Growth Have Greater Benefit From
           Endovascular Therapy

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      Authors: Longting Lin Hao Zhang Chushuang Chen Andrew Bivard Kenneth Butcher Carlos Garcia-Esperon Neil J. Spratt Christopher R. Levi Mark W. Parsons Gang Li South Western Clinical School; Faculty of Medicine, University of New South Wales, Sydney, Australia. (L.L., M.W.P.) Prince of Wales Clinical School, University of New South Wales, Sydney, Australia. (K.B.) Faculty of Health, University of Newcastle, Hunter Medical Research Institute, Australia (L.L., C.C., C.G.-E., N.J.S., C.R.L., M.W.P.). Department of Neurology, John Hunter Hospital, Newcastle, Australia (L.L., C.C., C.G.-E., N.J.S., C.R.L., M.W.P.). Shanghai East Hospital, Tongji University, China (H.Z., G.L.). Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Australia (A.B., M.W.P.). The Sydney Partnership for Health, Education, Research Enterprise, Australia (C.R.L.). , on behalf of INSPIRE Study Group Ferdinand Miteff Philip M. C. Choi Timothy Kleining Billy O’Brien Min Lou Jianhong Yang Congguo Yin Peng Wang Yu Geng Xu Zhang Xuezhi Yang Weiwen Qiu Qi Fang Yi Sui Wenhuo Chen Xin Cheng Qiang Dong
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:This study aimed to explore whether the therapeutic benefit of endovascular thrombectomy (EVT) was mediated by core growth rate.Methods:This retrospective cohort study identified acute ischemic stroke patients with large vessel occlusion and receiving reperfusion treatment, either EVT or intravenous thrombolysis (IVT), within 4.5 hours of stroke onset. Patients were divided into 2 groups: EVT versus IVT only patients (who had no access to EVT). Core growth rate was estimated by the acute core volume on perfusion computed tomography divided by the time from stroke onset to perfusion computed tomography. The primary clinical outcome was good outcome defined by 3-month modified Rankin Scale score of 0–2. Tissue outcome was the final infarction volume.Results:A total of 806 patients were included, 429 in the EVT group (recanalization rate of 61.6%) and 377 in the IVT only group (recanalization rate of 44.7%). The treatment effect of EVT versus IVT only was mediated by core growth rate, showing a significant interaction between EVT treatment and core growth rate in predicting good clinical outcome (interaction odds ratio=1.03 [1.01–1.05],P=0.007) and final infarct volume (interaction odds ratio=−0.44 [−0.87 to −0.01],P=0.047). For patients with fast core growth of >25 mL/h, EVT treatment (compared with IVT only) increased the odds of good clinical outcome (adjusted odds ratio=3.62 [1.21–10.76],P=0.021) and resulted in smaller final infarction volume (37.5 versus 73.9 mL,P=0.012). For patients with slow core growth of <15 mL/h, there were no significant differences between the EVT and the IVT only group in either good clinical outcome (adjusted odds ratio=1.44 [0.97–2.14],P=0.070) or final infarction volume (22.6 versus 21.9 mL,P=0.551).Conclusions:Fast core growth was associated with greater benefit from EVT compared with IVT in the early <4.5-hour time window.
      Citation: Stroke
      PubDate: 2021-09-29T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034205
       
  • Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients
           With Intracerebral Hemorrhage With Impaired Consciousness

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      Authors: Ayham Alkhachroum Antonio J. Bustillo Negar Asdaghi Erika Marulanda-Londono Carolina M. Gutierrez Daniel Samano Evie Sobczak Dianne Foster Mohan Kottapally Amedeo Merenda Sebastian Koch Jose G. Romano Kristine O’Phelan Jan Claassen Ralph L. Sacco Tatjana Rundek Department of Neurology, University of Miami, FL (A.A; A.J.B, N.A, E.M.-L, C.M.G, D.S, E.S, M.K, A.M, S.K, J.G.R, K.O, R.L.S, T.R.). Department of Neurology, Jackson Memorial Hospital, Miami, FL (A.A, A.J.B, N.A, E.M.-L, C.M.G, D.S, E.S, M.K, A.M, S.K, J.G.R, K.O, R.L.S, T.R.). Regional Director Quality Improvement, American Heart Association (D.F.). Department of Neurology, Columbia University, NY (J.C).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST).Methods:Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition.Results:Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1–4.3],P<0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3–0.4],P<0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152–229],P<0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate.Conclusions:In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.
      Citation: Stroke
      PubDate: 2021-09-29T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.035233
       
  • Role of Apparent Diffusion Coefficient Gradient Within Diffusion Lesions
           in Outcomes of Large Stroke After Thrombectomy

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      Authors: Dong-Seok Gwak WooChan Choi Dong-Hyun Shim Yong-Won Kim Dong-Hun Kang Wonsoo Son Yang-Ha Hwang Department of Neurology, Kyungpook National University Hospital, Daegu, Republic of Korea (D.-S.G; W.C.C, D.-H.S, Y.-W.K, Y.-H.H.). Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea. (Y.-W.K, Y.-H.H.) Department of Radiology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea. (D.-H.K, W.S.) Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea. (D.-H.K, W.S.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The outcome of endovascular treatment in stroke patients with a large ischemic core is not always satisfactory. We evaluated whether the severity of baseline diffusion-weighted imaging abnormalities, as assessed by different apparent diffusion coefficient (ADC) thresholds, correlates with the clinical outcome in these patients after successful endovascular treatment.Methods:In 82 consecutive patients with a large vessel occlusion in the anterior circulation admitted ≤24 hours after onset, a baseline diffusion lesion volume (ADC ≤620×10−6mm2/s [ADC620]) ≥50 mL and successful recanalization by endovascular treatment were retrospectively investigated. Lesion volumes of 3 ADC thresholds (ADC620, ADC ≤520×10−6mm2/s [ADC520], and ADC ≤540×10−6mm2/s [ADC540]) were measured using an automated Olea software program. The performance of the ADC520/ADC620and ADC540/ADC620ratios in predicting the functional outcome was assessed by receiver operating characteristic curve analysis. The ADC ratio with optimal threshold showing better receiver operating characteristic performance was dichotomized at its median value into low versus high subgroup and its association with the outcome subsequently evaluated in a multivariable logistic regression model.Results:The median baseline diffusion lesion volume was 80.8 mL (interquartile range, 64.4–105.4). A good functional outcome (modified Rankin Scale score, ≤2) was achieved in 35 patients (42.7%). The optimal threshold for predicting the functional outcome was identified as ADC540/ADC620(area under the curve, 0.833) and dichotomized at 0.674. After adjusting for age, baseline National Institutes of Health Stroke Scale score, intravenous tissue-type plasminogen activator, baseline diffusion lesion volume, and onset-to-recanalization time, a low ADC540/ADC620was independently associated with a good functional outcome (adjusted odds ratio, 10.72 [95% CI, 3.06–37.50];P<0.001).Conclusions:A low ADC540/ADC620, which may reflect less severe ischemic stress inside a diffusion lesion, may help to identify patients who would benefit from endovascular treatment despite having a large ischemic core.
      Citation: Stroke
      PubDate: 2021-09-29T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.035615
       
  • Efficacy of Intravenous Mesenchymal Stem Cells for Motor Recovery After
           Ischemic Stroke: A Neuroimaging Study

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      Authors: Jungsoo Lee Won Hyuk Chang Jong-Won Chung Soo-Kyoung Kim Jin Soo Lee Sung-Il Sohn Yun-Hee Kim Oh Young Bang Department of Physical; Stem Cell Research Laboratory on Stroke, Samsung Medical Center, Seoul, South Korea (J.-W.C., O.Y.B.). Department of Neurology, Gyeongsang National University School of Medicine, Jinju, South Korea (S.-K.K.). Departments of Neurology, Ajou University Hospital, School of Medicine, Suwon, South Korea (J.S.L.). Department of Neurology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea (S.-I.S.). , STARTING-2 Collaborators Suk Jae Kim Yeon Hee Cho Ji Hee Sung Eun Hee Kim Jeong Pyo Son Dong Hee Kim Eun-Hyeok Choi Sookyung Ryoo Yoon Mi Kang Yong Man Kim Hyun Soo Kim Jun Ho Jang
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Stem cell–based therapy is a promising approach to repair brain damage after stroke. This study was conducted to investigate changes in neuroimaging measures using stem cell–based therapy in patients with ischemic stroke.Methods:In this prospective, open-label, randomized controlled trial with blinded outcome evaluation, patients with severe middle cerebral artery territory infarct were assigned to the autologous mesenchymal stem cell (MSC) treatment or control group. Of 54 patients who completed the intervention, 31 for the MSC and 13 for the control groups were included in this neuroimaging analysis. Motor function was assessed before the intervention and 90 days after randomization using the Fugl-Meyer assessment scale. Neuroimaging measures included fractional anisotropy values of the corticospinal tract and posterior limb of the internal capsule from diffusion tensor magnetic resonance imaging and strength of connectivity, efficiency, and density of the motor network from resting-state functional magnetic resonance imaging.Results:For motor function, the improvement ratio of the Fugl-Meyer assessment score was significantly higher in the MSC group compared with the control group. In neuroimaging, corticospinal tract and posterior limb of the internal capsule fractional anisotropy did not decrease in the MSC group but significantly decreased at 90 days after randomization in the control group. Interhemispheric connectivity and ipsilesional connectivity significantly increased in the MSC group. Change in interhemispheric connectivity showed a significant group difference.Conclusions:Stem cell–based therapy can protect corticospinal tract against degeneration and enhance positive changes in network reorganization to facilitate motor recovery after stroke.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT01716481.
      Citation: Stroke
      PubDate: 2021-09-29T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034505
       
  • Neuroticism Increases the Risk of Stroke: Mendelian Randomization Study

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      Authors: Yaozhong Liu Peng Cheng Na Liu Biao Li Yingxu Ma Wanyun Zuo Qiming Liu Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University, Hunan Province, China. (Y.L; N.L, B.L, Y.M, W.Z, Q.L.) Department of Psychiatry, Second Xiangya Hospital, Central South University, Hunan Province, China. (P.C.)
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-09-29T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.036131
       
  • Future Shock: Does Pessimism Contribute to Poor Outcome After
           Intracerebral Hemorrhage'

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      Authors: H.E. Hinson Departments of Neurology; Science University, Portland.
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-09-29T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.036761
       
  • Infarct Core Growth Velocity: Characterizing the Hot Penumbra Without
           Looking at It

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      Authors: Juan F. Arenillas Stroke Program; Department of Neurology, Hospital Clínico Universitario Valladolid, Spain. Clinical Neurosciences Research Group, Department of Medicine, University of Valladolid, Spain.
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-09-29T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.035682
       
  • Mendelian Randomization Focused Analysis of Vitamin D on the Secondary
           Prevention of Ischemic Stroke

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      Authors: Yap-Hang Chan C. Mary Schooling Jie Zhao Shiu-Lun Au Yeung Jo Jo Hai G. Neil Thomas Kar-Keung Cheng Chao-Qiang Jiang Yuen-Kwun Wong Ka-Wing Au Clara S. Tang Chloe Y.Y. Cheung Aimin Xu Pak-Chung Sham Tai-Hing Lam Karen Siu-Ling Lam Hung-Fat Tse Division of Cardiology; Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China. (Y.-H.C., J.J.H., Y.-K.W., K.-W.A., H.-F.T.) School of Public Health, The University of Hong Kong, Hong Kong SAR, China. (C.M.S., J.Z., S.-L.A.Y., T.-H.L.) Department of Psychiatry Epidemiology, University of Birmingham, United Kingdom (G.N.T., K.-K.C.). Guangzhou No. 12 Hospital, People’s Republic of China (C.-Q.J.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Experimental studies showed vitamin D (Vit-D) could promote vascular regeneration and repair. Prior randomized studies had focused mainly on primary prevention. Whether Vit-D protects against ischemic stroke and myocardial infarction recurrence among subjects with prior ischemic insults was unknown. Here, we dissected through Mendelian randomization any effect of Vit-D on the secondary prevention of recurrent ischemic stroke and myocardial infarction.Methods:Based on a genetic risk score for Vit-D constructed from a derivation cohort sample (n=5331, 45% Vit-D deficient, 89% genotyped) via high-throughput exome-chip screening of 12 prior genome-wide association study–identified genetic variants of Vit-D mechanistic pathways (rs2060793,rs4588, andrs7041; F statistic, 73;P<0.001), we performed a focused analysis on prospective recurrence of myocardial infarction (MI) and ischemic stroke in an independent subsample with established ischemic disease (n=441, all with prior first ischemic event; follow-up duration, 41.6±14.3 years) under a 2-sample, individual-data, prospective Mendelian randomization approach.Results:In the ischemic disease subsample, 11.1% (n=49/441) had developed recurrent ischemic stroke or MI and 13.3% (n=58/441) had developed recurrent or de novo ischemic stroke/MI. Kaplan-Meier analyses showed that genetic risk score predicted improved event-free survival from recurrent ischemic stroke or MI (log-rank, 13.0;P=0.001). Cox regression revealed that genetic risk score independently predicted reduced risk of recurrent ischemic stroke or MI combined (hazards ratio, 0.62 [95% CI, 0.48–0.81];P<0.001), after adjusted for potential confounders. Mendelian randomization supported that Vit-D is causally protective against the primary end points of recurrent ischemic stroke or MI (Wald estimate: odds ratio, 0.55 [95% CI, 0.35–0.81]) and any recurrent or de novo ischemic stroke/MI (odds ratio, 0.64 [95% CI, 0.42–0.91]) and recurrent MI alone (odds ratio, 0.52 [95% CI, 0.30–0.81]).Conclusions:Genetically predicted lowering in Vit-D level is causal for the recurrence of ischemic vascular events in persons with prior ischemic stroke or MI.
      Citation: Stroke
      PubDate: 2021-09-27T09:00:04Z
      DOI: 10.1161/STROKEAHA.120.032634
       
  • Objectively Measured Physical Activity and Sedentary Time Among Adults
           With and Without Stroke: A National Cohort Study

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      Authors: Andrea T. Duran Christian B. Pascual Jeff Goldsmith Virginia J. Howard Brent Hutto Natalie Colabianchi John E. Vena Michelle N. McDonnell Steven N. Blair Steven P. Hooker Keith M. Diaz Center for Behavioral Cardiovascular Health; Columbia University Irving Medical Center, New York, NY (A.T.D., K.M.D.). School of Public Health, University of California, San Diego (C.B.P.). Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY (J.G.). Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (V.J.H.). Arnold School of Public Health (B.H.) University of South Carolina, Columbia (S.N.B.). School of Kinesiology Human Services, San Diego State University, CA (S.P.H.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:We examined differences in the volume and pattern of physical activity (PA) and sedentary behavior between adults with and without stroke.Methods:We studied cohort members with an adjudicated or self-reported stroke (n=401) and age-, sex-, race-, region of residence-, and body mass index-matched participants without a history of stroke (n=1203) from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke). Sedentary behavior (total volume and bouts), light-intensity PA, and moderate-to-vigorous-intensity PA were objectively measured for 7 days via hip-worn accelerometer.Results:Sedentary time (790.5±80.4 versus 752.4±81.9 min/d) and mean sedentary bout duration (15.7±12.6 versus 11.9±8.1 min/d) were higher and PA (light-intensity PA: 160.5±74.6 versus 192.9±73.5 min/d and moderate-to-vigorous-intensity PA: 9.0±11.9 versus 14.7±17.0 min/d) lower for stroke survivors compared with controls (P<0.001). Stroke survivors also accrued fewer activity breaks (65.5±21.9 versus 73.31±18.9 breaks/d) that were shorter (2.4±0.7 versus 2.7±0.8 minutes) and lower in intensity (188.4±60.8 versus 217.9±72.2 counts per minute) than controls (P<0.001).Conclusions:Stroke survivors accrued a lower volume of PA, higher volume of sedentary time, and exhibited accrual patterns of more prolonged sedentary bouts and shorter, lower intensity activity breaks compared with persons without stroke.
      Citation: Stroke
      PubDate: 2021-09-27T09:00:04Z
      DOI: 10.1161/STROKEAHA.121.034194
       
  • Automated Brain Perfusion Imaging in Acute Ischemic Stroke: Interpretation
           Pearls and Pitfalls

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      Authors: Manal Nicolas-Jilwan Max Wintermark Division of Neuroradiology; Department of Radiology, King Faisal Specialist Hospital Neurointervention, Department of Radiology, Stanford Healthcare, CA (M.W.).
      Abstract: Stroke, Ahead of Print.
      Recent advancements in computed tomography technology, including improved brain coverage and automated processing of the perfusion data, have reinforced the use of perfusion computed tomography imaging in the routine evaluation of patients with acute ischemic stroke. The DAWN (Diffusion Weighted Imaging or Computerized Tomography Perfusion Assessment With Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention) and DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) trials have established the benefit of endovascular thrombectomy in patients with acute ischemic stroke with anterior circulation large vessel occlusion up to 24 hours of last seen normal, using perfusion imaging-based patient selection. The compelling data has prompted stroke centers to increasingly introduce automated perfusion computed tomography imaging in the routine evaluation of patients with acute ischemic stroke. We present a comprehensive overview of the acquisition and interpretation of automated perfusion imaging in patients with acute ischemic stroke with a special emphasis on the interpretation pearls, pitfalls, and stroke mimicking conditions.
      Citation: Stroke
      PubDate: 2021-09-27T09:00:04Z
      DOI: 10.1161/STROKEAHA.121.035049
       
  • Endovascular Treatment of Acute Ischemic Stroke With the Penumbra System
           in Routine Practice: COMPLETE Registry Results

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      Authors: Osama O. Zaidat Johanna T. Fifi Ashish Nanda Benjamin Atchie Keith Woodward Arnd Doerfler Alejandro Tomasello Wondwossen Tekle Inder Paul Singh Charles Matouk Jörg Thalwitzer Tomasz Jargiełło Dmitry Skrypnik Oliver Beuing Jérôme Berge Jeffrey M. Katz Alessandra Biondi David Bonovich Sunil A. Sheth Albert J. Yoo Ameer E. Hassan Mercy Health St. Vincent Medical Center; Toledo, OH (O.O.Z.). Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.). SSM St. Clare Healthcare, Fenton, MO (A.N.). RIA Neurovascular, Englewood, CO (B.A.). Fort Sanders Regional Medical Center, Knoxville, TN (K.W.). Universitätsklinikum Erlangen, Germany (A.D.). Hospital Universitari Vall d’Hebron, Barcelona, Spain (A.T.). University of Texas Rio Grande Valley - Valley Baptist Health System, Harlingen (W.T.). Mount Sinai Health System, New York, NY (I.P.S.). Yale New Haven Hospital, New Haven, CT (C.M.). Klinikum Chemnitz GmbH, Chemnitz, Germany (J.T.). Samodzielny Publiczny Szpital Kliniczny nr 4, Lublin, Poland (T.J.). Moscow City Clinical Hospital named after Davydovsky, Russia (D.S.). Universitätsklinikum Magdeburg, Germany (O.B.). CHU de Bordeaux- Hôpital Pellegrin, Bordeaux, France (J.B.). North Shore University Hospital, Northwell Health, Manhasset, NY (J.M.K.). J Minjoz University Hospital, Besançon, France (A.B.). Eden Medical Center, Castro Valley, CA (D.B.). Department of Neurology, UTHealth McGovern Medical School, Houston, TX (S.A.S.). Texas Stroke Institute, Dallas-Fort Worth (A.J.Y.). University of Texas Rio Grande Valley - Valley Baptist Medical Center, Harlingen (A.E.H.). , on behalf of the COMPLETE Registry Investigators* Michel Piotin Raphaël Blanc Jean-Philippe Desilles Gabriele Ciccio Stanislas Smajda Gaultier Marnat Xavier Barreau Patrice Ménégon Florent Gariel Tobias Engelhorn Philipp Gölitz Manuel Schmidt Stefan Lang Iris Mühlen Julie Rösch Michael Knott Hannes Lücking Philip Hoelter Peter Schramm Alexander Neumann Thomas Eckey Tobias Boppel Mike Krah Jens Schwarze Bettina Manikowski Philipp Ladig Nathanael Albert Carmen Otto Anne Lemme Silvio Brandt Georg Bohner Justus Kleine Eberhard Siebert Hans-Christian Bauknecht Edzard Wiener Aneta Donitza Michał Górnik Krzysztof Pyra Tomasz Roman Maciej Szajner Remigiusz Ficek Katarzyna Prus(Sub-I) Sylwia Stachowicz Joanna Wojczal Michał Sojka Kinga Buraczyńska Piotr Luchowski Kirill Anisimov Ekaterina Sukhanova Eugene Shloydo Kirill Kravchenko Konstantin Golikov Aleksey Sergeev Anna Udovichenko Roman Georgiev Eduard Gasparyan Svyatoslav Malov Eugeny Ploschenkov Marc Ribó David Hernández David Rodriguez-Luna Álvaro García-Tornel Marta Rubiera Jesús Juega Marian Muchada Noelia Rodríguez Villatoro Sandra Boned Riera Jorge Pagola Matías Deck Román Carlos Piñana Plaza Joaquín Zamarro Parra Guillermo Parrilla Reverter Mariano Espinosa de Rueda Ruiz Blanca García-Villalba Navaridas José Díaz Pérez Frank Hellinger Ravi Gandhi Michael Bellew Richard Bellon Do Frei Ian Kaminsky Eric Arias Henry Woo Ina Teron Molina Anand Patel Richard Libman Rohan Arora Harry Hixson Cole Graham Roham Moftakhar Orlando Diaz Richard Klucznik Michael Alexander Robert Jackson Matthew Padrick Oana Dumitrascu Konrad Schlick Edgar Olivas Shlee Song Zachary Barnard Penelope Kornbluth Ernest John Madarang Alan Reeves Hazem Shoriah Kurt Yaeger Shahram Majidi Reade DeLacey Christopher Keller Tomoyoshi Shigematsu Gal Yaniv Thomas Oxley Alexandros Georgiadis Ryan Herber Farhad Bahrassa Michele Johnson Harris Hawk Steven Quarfordt Michael Nichols Justin Calvert Robert Starke Dileep Yavagal Eric Peterson Dorothea Altschul Ahsan Sattar Mohammed Ali Aziz-Sultan Daniel Large Nirav Patel Karen Chen Habibullah Ziayee Rose Du Kai Frerichs Akshal Patel Stephen Monteith Yince Loh Mohammed Aref Stavropoula Tjoumakaris Nabeel Herial Pacal Jabbour Robert Rosenwasser Michael Reid Gooch Hekmat Zarzour Muhammad Taqi Daniel Hoit Adam Arthur Lucas Elijovich Christopher Nickele Violiza Inoa Nitin Goyal Radmehr Torabi David Dornbos Jeremy Peterson Lucian Maidan George Luh Sushant Kale Amer Alshekhlee Hamed Farid Aaron Bress Cagin Senturk Jim Milburn Gabriel Vidal Paul Gulotta Edison Valle-Giler David Turkel-Parrella David S. Gordon Jeremy Liff Karthik Arcot Jeffrey Farkas Peter Adamczyk Eugene Lin Mohammad Ezzeldin Ali Sultan-Qurraie Badar Alenzi Mohamed Teleb Mazen Abuawad Ruta Viktoria Totoraitis Paul Richard
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The purpose of the COMPLETE (International Acute Ischemic Stroke Registry With the Penumbra System Aspiration Including the 3D Revascularization Device) registry was to evaluate the generalizability of the safety and efficacy of the Penumbra System (Penumbra, Inc, Alameda) in a real-world setting.Methods:COMPLETE was a global, prospective, postmarket, multicenter registry. Patients with large vessel occlusion–acute ischemic stroke who underwent mechanical thrombectomy using the Penumbra System with or without the 3D Revascularization Device as frontline approach were enrolled at 42 centers (29 United States, 13 Europe) from July 2018 to October 2019. Primary efficacy end points were successful postprocedure angiographic revascularization (modified Thrombolysis in Cerebral Infarction ≥2b) and 90-day functional outcome (modified Rankin Scale score 0–2). The primary safety end point was 90-day all-cause mortality. An imaging core lab determined modified Thrombolysis in Cerebral Infarction scores, Alberta Stroke Program Early CT Scores, clot location, and occurrence of intracranial hemorrhage at 24 hours. Independent medical reviewers adjudicated safety end points.Results:Six hundred fifty patients were enrolled (median age 70 years, 54.0% female, 49.2% given intravenous recombinant tissue plasminogen activator before thrombectomy). Rate of modified Thrombolysis in Cerebral Infarction 2b to 3 postprocedure was 87.8% (95% CI, 85.3%–90.4%). First pass and postprocedure rates of modified Thrombolysis in Cerebral Infarction 2c to 3 were 41.5% and 66.2%, respectively. At 90 days, 55.8% (95% CI, 51.9%–59.7%) had modified Rankin Scale score 0 to 2, and all-cause mortality was 15.5% (95% CI, 12.8%–18.3%).Conclusions:Using Penumbra System for frontline mechanical thrombectomy treatment of patients with large vessel occlusion–acute ischemic stroke in a real-world setting was associated with angiographic, clinical, and safety outcomes that were comparable to prior randomized clinical trials with stringent site and operator selection criteria.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT03464565.
      Citation: Stroke
      PubDate: 2021-09-22T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034268
       
  • Angiographic and Hemodynamic Features in Asymptomatic Hemispheres of
           Patients With Moyamoya Disease

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      Authors: Haogeng Sun Wanjiang Li Chao Xia Yutao Ren Lu Ma Anqi Xiao Chao You Yi Liu Rui Tian Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China. (H.S; C.X, Y.R, L.M, A.X, C.Y, Y.L, R.T.) Department of Radiology, West China Hospital, Sichuan University, Chengdu, China. (W.L.) George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (C.X.). West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu (L.M, A.X, C.Y, Y.L, R.T.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:There is also a risk of stroke in the asymptomatic hemispheres of moyamoya disease (MMD), but it does not draw enough attention. The study investigated the differences between the three types of asymptomatic hemispheres in MMD and their associations with the two types of symptomatic hemispheres, respectively.Methods:Retrospectively reviewed clinical and imaging characteristics of asymptomatic and symptomatic hemispheres in consecutive cases of single-center MMD patients, with an emphasis on imaging characterization regarding vascular morphology and cerebral perfusion. MMD hemispheres were categorized into 5 types: hemorrhagic hemispheres, ischemic hemispheres, asymptomatic hemispheres in unilateral hemorrhagic MMD, asymptomatic hemispheres in unilateral ischemic MMD, and bilateral asymptomatic hemispheres in MMD. Angiographic feature was assessed by Suzuki’s angiographic stage, while hemodynamic feature was assessed by preinfarction period stage.Results:One hundred ninety-four MMD patients with 388 hemispheres were enrolled. Asymptomatic hemispheres in unilateral hemorrhagic MMD were largely similar to hemorrhagic hemispheres, both had more advanced Suzuki’s angiographic stage and lower degree of hemodynamic failure compared with bilateral asymptomatic hemispheres in MMD and asymptomatic hemispheres in unilateral ischemic MMD. Asymptomatic hemispheres in unilateral ischemic MMD were similar to ischemic hemispheres, both had less advanced Suzuki’s angiographic stage and higher degree of hemodynamic failure compared with bilateral asymptomatic hemispheres in MMD and asymptomatic hemispheres in unilateral hemorrhagic MMD. Bilateral asymptomatic hemispheres in MMD were different from the other hemispheres and had less advanced Suzuki’s angiographic stage and lower degree of hemodynamic failure.ConclusionS:The three types of asymptomatic hemispheres in MMD are defined and have unique angiographic and hemodynamic features. Different combinations of the two features can reflect the tendency of pathological evolution in these different asymptomatic hemispheres.
      Citation: Stroke
      PubDate: 2021-09-22T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.035296
       
  • Blood Pressure in the First 6 Hours Following Endovascular Treatment for
           Ischemic Stroke Is Associated With Outcome

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      Authors: Noor Samuels Rob A. van de Graaf Carlijn A.L. van den Berg Simone M. Uniken Venema Kujtesa Bala Pieter Jan van Doormaal Wouter van der Steen Elbert Witvoet Jelis Boiten Heleen den Hertog Wouter J. Schonewille Jeannette Hofmeijer Floris Schreuder Tobien A.H.C.M.L. Schreuder H. Bart van der Worp Yvo B.W.E.M. Roos Charles B.L.M. Majoie James F. Burke Adriaan C.G.M. van Es Aad van der Lugt Bob Roozenbeek Hester F. Lingsma Diederik W.J. Dippel Department of Neurology; Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.) Department of Radiology Nuclear Medicine, Leiden University Medical Center, the Netherlands (A.C.G.M.v.E.). , on behalf of the MR CLEAN Registry Investigators Robert J. van Oostenbrugge Wim H. van Zwam Jan Albert Vos Ivo G.H. Jansen Maxim J.H.L. Mulder Robert- Jan B. Goldhoorn Kars C.J. Compagne Manon Kappelhof Josje Brouwer Sanne J. den Hartog Wouter H. Hinsenveld Bart J. Emmer Jonathan M. Coutinho Jan Albert Vos Marieke J.H. Wermer Marianne A.A. van Walderveen Julie Staals Robert J. van Oostenbrugge Wim H. van Zwam Jasper M. Martens Geert J. Lycklama à Nijeholt Sebastiaan F. de Bruijn Lukas C. van Dijk Rob H. Lo Ewoud J. van Dijk Hieronymus D. Boogaarts J. de Vries Paul L.M. de Kort Julia van Tuijl Jo P. Peluso Puck Fransen Jan S.P. van den Berg Boudewijn A.A.M. van Hasselt Leo A.M. Aerden J. Dallinga René Maarten Uyttenboogaart Omid Eschgi Reinoud P.H. Bokkers Roel J.J. Heijboer Koos Keizer Lonneke S.F. Yo Emiel J.C. Sturm Paul J.A.M. Brouwers Wim H. van Zwam Geert J. Lycklama à Nijeholt Marianne A.A. van Walderveen Marieke E.S. Sprengers Sjoerd F.M. Jenniskens René van den Berg Albert J. Yoo Ludo F.M. Beenen Alida A. Postma Stefan D. Roosendaal Bas F.W. van der Kallen Ido R. van den Wijngaard Bart J. Emmer Jasper M. Martens Lonneke S.F. Yo Jan Albert Vos Joost Bot Anton Meijer Elyas Ghariq Reinoud P.H. Bokkers Marc P. van Proosdij G. Menno Krietemeijer Jo P. Peluso Hieronymus D. Boogaarts Rob Lo Dick Gerrits Wouter Dinkelaar Auke P.A. Appelman Bas Hammer Sjoert Pegge Anouk van der Hoorn Saman Vinke Robert J. van Oostenbrugge Wim H. van Zwam Geert J. Lycklama à Nijeholt Jan Albert Vos Jasper M. Martens Rob H. Lo Robert J. van Oostenbrugge H. Zwenneke Flach Naziha el Ghannouti Martin Sterrenberg Corina Puppels Wilma Pellikaan Rita Sprengers Marjan Elfrink Michelle Simons Marjolein Vossers Joke de Meris Tamara Vermeulen Annet Geerlings Gina van Vemde Tiny Simons Cathelijn van Rijswijk Gert Messchendorp Nynke Nicolaij Hester Bongenaar Karin Bodde Sandra Kleijn Jasmijn Lodico Hanneke Droste Maureen Wollaert Sabrina Verheesen D. Jeurrissen Erna Bos Yvonne Drabbe Michelle Sandiman Nicoline Aaldering Berber Zweedijk Mostafa Khalilzada Jocova Vervoort Eva Ponjee Sharon Romviel Karin Kanselaar Denn Barning Esmee Venema Vicky Chalos Ralph R. Geuskens Tim van Straaten Saliha Ergezen Roger R.M. Harmsma Daan Muijres Anouk de Jong Olvert A. Berkhemer Anna M.M. Boers J. Huguet P.F.C. Groot Marieke A. Mens Katinka R. van Kranendonk Kilian M. Treurniet Manon L. Tolhuisen Heitor Alves Annick J. Weterings Eleonora L.F. Kirkels Eva J.H.F. Voogd Lieve M. Schupp Sabine Collette Adrien E.D. Groot Natalie E. LeCouffe Praneeta R. Konduri Haryadi Prasetya Nerea Arrarte-Terrero Lucas A. Ramos
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Optimal blood pressure (BP) management in the acute phase of ischemic stroke remains an unresolved issue. It is uncertain whether guidelines for BP management during and after intravenous alteplase can be extrapolated to endovascular treatment (EVT) for stroke due to large artery occlusion in the anterior circulation. We evaluated the associations between systolic BP (SBP) in the first 6 hours following EVT and functional outcome as well as symptomatic intracranial hemorrhage.Methods:Patients of 8 MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry centers, with available data on SBP in the 6 hours following EVT, were analyzed. We evaluated maximum, minimum, and mean SBP. Study outcomes were functional outcome (modified Rankin Scale) at 90 days and symptomatic intracranial hemorrhage. We used multivariable ordinal and binary regression analysis to adjust for important prognostic factors and studied possible effect modification by successful reperfusion.Results:Post-EVT SBP data were available for 1161/1796 patients. Higher maximum SBP (per 10 mm Hg increments) was associated with worse functional outcome (adjusted common odds ratio, 0.93 [95% CI, 0.88–0.98]) and a higher rate of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.17 [95% CI, 1.02–1.36]). The association between minimum SBP and functional outcome was nonlinear with an inflection point at 124 mm Hg. Minimum SBP lower and higher than the inflection point were associated with worse functional outcomes (adjusted common odds ratio, 0.85 per 10 mm Hg decrements [95% CI, 0.76–0.95] and adjusted common odds ratio, 0.81 per 10 mm Hg increments [95% CI, 0.71–0.92]). No association between mean SBP and functional outcome was observed. Successful reperfusion did not modify the relation of SBP with any of the outcomes.Conclusions:Maximum SBP in the first 6 hours following EVT is positively associated with worse functional outcome and an increased risk of symptomatic intracranial hemorrhage. Both lower and higher minimum SBP are associated with worse outcomes. A randomized trial to evaluate whether modifying post-intervention SBP results in better outcomes after EVT for ischemic stroke seems justified.
      Citation: Stroke
      PubDate: 2021-09-20T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.033657
       
  • Endovascular Thrombectomy for Treatment of Acute Ischemic Stroke During
           Pregnancy and the Early Postpartum Period

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      Authors: Alis J. Dicpinigaitis Tolga Sursal Catherine A. Morse Camille Briskin Katarina Dakay Christeena Kurian Gurmeen Kaur Ramandeep Sahni Christian Bowers Chirag D. Gandhi Stephan A. Mayer Fawaz Al-Mufti School of Medicine, New York Medical College, Valhalla, Westchester Medical Center, Valhalla, NY. (A.L.D; C.A.M, C.B.). Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (T.S, C.D.G.) Department of Neurology, Westchester Medical Center, Valhalla, NY. (K.D, C.K, G.K, R.S, S.A.M, F.A.-M.) Department of Neurosurgery, University of New Mexico, Albuquerque (C.B.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Acute ischemic stroke (AIS) is a rare occurrence during pregnancy and the postpartum period. Existing literature evaluating endovascular mechanical thrombectomy (MT) for this patient population is limited.Methods:The National Inpatient Sample was queried from 2012 to 2018 to identify and characterize pregnant and postpartum patients (up to 6 weeks following childbirth) with AIS treated with MT. Complications and outcomes were compared with nonpregnant female patients treated with MT and to other pregnant and postpartum patients managed medically. Complex samples regression models and propensity score matching were implemented to assess adjusted associations and to address confounding by indication, respectively.Results:Among 4590 pregnant and postpartum patients with AIS, 180 (3.9%) were treated with MT, and rates of utilization increased following the MT clinical trial era (2015–2018; 1.9% versus 5.3%,P=0.011). Compared with nonpregnant patients with AIS treated with MT, they experienced lower rates of intracranial hemorrhage (11% versus 24%,P=0.069) and poor functional outcome (50% versus 72%,P=0.003) at discharge. Pregnant/postpartum status was independently associated with a lower likelihood of development of intracranial hemorrhage (adjusted odds ratio, 0.26 [95% CI, 0.09–0.70];P=0.008) following multivariable analysis adjusting for age, illness severity, and stroke severity. Following propensity score matching, pregnant and postpartum patients treated with MT and those medically managed differed in frequency of venous thromboembolism (17% versus 0%,P=0.001) and complications related to pregnancy (44% versus 64%,P=0.034), but not in functional outcome at discharge or hospital length of stay. Pregnant and postpartum women treated with MT did not experience mortality or miscarriage during hospitalization.Conclusions:This large-scale analysis utilizing national claims data suggests that MT is a safe and efficacious therapy for AIS during pregnancy and the postpartum period. In the absence of prospective clinical trials, population-based cross-sectional analyses such as the present study provide valuable clinical insight.
      Citation: Stroke
      PubDate: 2021-09-20T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.034303
       
  • Effect of Adjusted Antiplatelet Therapy on Preventing Ischemic Events
           After Stenting for Intracranial Aneurysms

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      Authors: Wenqiang Li Wei Zhu Anxin Wang Guojun Zhang Yisen Zhang Kun Wang Ying Zhang Chao Wang Limin Zhang Hui Zhao Ping Wang Kelin Chen Jian Liu Xinjian Yang Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China. (W.L; W.Z, Yisen Zhang, K.W, Ying Zhang, C.W, J.L, X.Y.) China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W.) Laboratory Diagnosis Center, Beijing Tiantan Hospital, Capital Medical University, China. (G.Z, L.Z, H.Z, P.W, K.C.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:This study tests whether patients with unruptured intracranial aneurysm who underwent stent placement benefitted from platelet function monitoring–guided adjustment of antiplatelet therapy.Methods:We conducted a randomized, open-label, parallel group, assessor-blinded trial. Patients with unruptured intracranial aneurysm who underwent stent placement were assigned in a 1:1 ratio to receive either drug adjustment (patients who had high on-treatment platelet reactivity to antiplatelet therapy on the basis of platelet function monitoring [monitoring group]) or conventional therapy (without monitoring and drug adjustment [conventional group]). The second monitoring was performed 14 days after randomization in patients with drug adjustment. The primary outcome was the composite frequency of ischemic stroke, transient ischemic attack, stent thrombosis, urgent revascularization, and cerebrovascular death within 7 days after stent implantation. The safety outcome was the composite frequency of major, minor, or minimal bleeding within 1 month after stent implantation.Results:In total, 314 patients were included (n=157 per group). The primary combined outcome occurred in 19 patients (12.1%) in the conventional group and 8 patients (5.1%) in the monitoring group (hazard ratio, 0.39 [95% CI, 0.17–0.92];P=0.03). Ischemic stroke occurred at a lower frequency in the monitoring group compared with that in the conventional group (4.5% versus 12.1%; hazard ratio, 0.34 [95% CI, 0.14–0.83];P=0.01), which drove the overall primary combined outcome. The safety outcome occurred in the monitoring group (7.0%) and in the conventional group (1.9%; hazard ratio, 3.87 [95% CI, 1.06–14.14];P=0.03). A significant difference was observed in the frequency of minor or minimal bleeding events between the two groups (monitoring group versus conventional group, 6.4% versus 1.3%;P=0.02) but not in the frequency of major bleeding events between the two groups.Conclusions:Platelet function monitoring–guided antiplatelet therapy reduces thromboembolic events in patients with unruptured intracranial aneurysm after stent placement, significantly enhancing minor or minimal bleeding events but not major bleeding events.Registration:URL:https://www.clinicaltrials.gov; Unique identifier: NCT03989557.
      Citation: Stroke
      PubDate: 2021-09-20T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.032989
       
  • Frequency and Patterns of Brain Infarction in Patients With Embolic Stroke
           of Undetermined Source: NAVIGATE ESUS Trial

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      Authors: Mukul Sharma Eric E. Smith Lesly A. Pearce Ashkan Shoamanesh Kanjana S. Perera Shelagh B. Coutts Dorte Damgaard Sebastian F. Ameriso Joung-Ho Rha Boris Modrau Byung-Woo Yoon Marina Romano Steven R. Messé Jessica Barlinn Johann Lambeck Feryal Saad Scott D. Berkowitz Hardi Mundl Stuart J. Connolly Robert G. Hart Department of Medicine (Neurology); McMaster University/Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada (M.S, A.S., K.S.P.). Department of Clinical Neurosciences, University of Calgary, Alberta, Canada (E.E.S.). Biostatistics Consultant, St. Catharines, Ontario, Canada (L.A.P.) Department of Clinical Neurosciences, Radiology, Clinical Neurophysiology, Universitätsklinikum Freiburg, Germany (J.L.). Pharmaceuticals, Clinical Development, Thrombosis & Vascular Medicine, Bayer U.S. LLC, Whippany, New Jersey (MD). Bayer AG, Wuppertal, Germany (H.M.). Population Health Research Institute, Hamilton Health Sciences, Ontario, Canada (R.G.H., S.J.C.). , on behalf of the NAVIGATE ESUS MIND MRI Substudy Investigators T.S. Field G.J. Stotts D.J. Gladstone S.J. Phillips A. Sharrief C. Holmstedt N. Vora C. Wilson B.M. Coull A. de Havenon L.A. Birnbaum N. Patel M.S. Hussain D. Greer S. Chen S. Kittner D. Mehta T. Lowenkopf R. Sawyer V. Babikian R. Zweifler D.L. Tirschwell C. Sila C. Zhang K-S. Hong K. Oh J.H. Heo H-J. Bae M.S. Park J.S. Kim C-S. Chung B-C. Lee G.P. Povedano J.J. Martin G.M. Bruera L.V. Jure J. Marti-Fabregas I.C. Naranjo J.M.R. Moreno P.C. Portela M. Gomis J. Serena H. Christensen T. Christensen S. Knecht M. Endres J. Berrouschot F. Schlachetzki S. Wunderlich P. Kraft P. Guyler RC. Veltkamp M. Burn K. Rashed M.J. Macleod C. Canepa J. Selvarajah D. Hargroves Y. Behnam T.G. Robinson L. Roveri G. Lembo D.S. Toni V. Monzani A. Cavallini D. Popov M. Friedrich C. Minelli C. Moro R.J. Gagliardi A. Bacellar R. Mikulik J. Eckstein G. Panczel N. Szegedi M.J. O’Donnell
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The spectrum of brain infarction in patients with embolic stroke of undetermined source (ESUS) has not been well characterized. Our objective was to define the frequency and pattern of brain infarcts detected by magnetic resonance imaging (MRI) among patients with recent ESUS participating in a clinical trial.Methods:In the NAVIGATE ESUS trial (New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial Versus ASA to Prevent Embolism in Embolic Stroke of Undetermined Source), an MRI substudy was carried out at 87 sites in 15 countries. Participants underwent an MRI using a specified protocol near randomization. Images were interpreted centrally by those unaware of clinical characteristics.Results:Among the 918 substudy cohort participants, the mean age was 67 years and 60% were men with a median (interquartile range) of 64 (26–115) days between the qualifying ischemic stroke and MRI. On MRI, 855 (93%) had recent or chronic brain infarcts that were multiple in 646 (70%) and involved multiple arterial territories in 62% (401/646). Multiple brain infarcts were present in 68% (510/755) of those without a history of stroke or transient ischemic attack before the qualifying ESUS. Prior stroke/transient ischemic attack (P<0.001), modified Rankin Scale score >0 (P<0.001), and current tobacco use (P=0.01) were associated with multiple infarcts. Topographically, large and/or cortical infarcts were present in 89% (757/855) of patients with infarcts, while in 11% (98/855) infarcts were exclusively small and subcortical. Among those with multiple large and/or cortical infarcts, 57% (251/437) had one or more involving a different vascular territory from the qualifying ESUS.Conclusions:Most patients with ESUS, including those without prior clinical stroke or transient ischemic attack, had multiple large and/or cortical brain infarcts detected by MRI, reflecting a substantial burden of clinical stroke and covert brain infarction. Infarcts most frequently involved multiple vascular territories.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT02313909.
      Citation: Stroke
      PubDate: 2021-09-20T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.032976
       
  • Relation Between the Corticospinal Tract State and Activities of Daily
           Living in Patients With Intracerebral Hemorrhage

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      Authors: Sung Ho Jang Eun Bi Choi Department of Physical Medicine; Rehabilitation, College of Medicine, Yeungnam University, Republic of Korea.
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:We investigated the relation between the ipsilesional corticospinal tract (CST) state and activity of daily living independence in patients with chronic intracerebral hemorrhage.Methods:Fifty-six consecutive patients with unilateral intracerebral hemorrhage and 38 healthy control subjects were recruited for this study. The Motricity index and the modified Barthel index were used to evaluate motor function of the affected extremities and activity of daily living independence, respectively. The diffusion tensor imaging parameter values for fractional anisotropy (FA) and voxel number (VN) of the CST were determined. Ratios of the ipsilesional to the contralesional CST measures were calculated and are presented as the CST-ratio (FA value and VN).Results:The FA value and VN of the ipsilesional CST and the CST-ratio in the patient group were lower than those of the control group (P<0.05). There was a strong positive correlation between the Motricity index score of the affected extremities and the modified Barthel index score (P<0.05), while the FA value and VN of the ipsilesional CST and the CST-ratio showed moderate and strong positive correlations with the Motricity index and modified Barthel index scores, respectively (P<0.05). In addition, the VN of the ipsilesional CST showed excellent utility as a classifier, whereas the FA value of the ipsilesional CST and the FA value and VN of the CST-ratio showed good classifier utility (P<0.05).Conclusions:We demonstrated that impairment of activity of daily living independency was closely related to the injury severity of the ipsilesional CST in patients with chronic intracerebral hemorrhage. In addition, the injury severity of the ipsilesional CST can be used to classify the degree of activity of daily living independency.REGISTRATION:URL:http://www.e-irb.com/index.jsp; Unique identifier: 2021-03-014.
      Citation: Stroke
      PubDate: 2021-09-20T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.034939
       
  • Cerebellar Superficial Siderosis in Cerebral Amyloid Angiopathy

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      Authors: Emma A. Koemans Sabine Voigt Ingeborg Rasing Thijs W. van Harten Wilmar M.T. Jolink Floris H.B.M. Schreuder Erik W. van Zwet Mark A. van Buchem Matthias J.P. van Osch Gisela M. Terwindt Catharina J.M. Klijn Marianne A.A. van Walderveen Marieke J.H. Wermer Department of Neurology; Leiden University Medical Center, the Netherlands. (E.A.K., S.V., I.R., G.M.T., M.J.H.W.) Department of Radiology, Leiden University Medical Center, the Netherlands. (T.W.v.H., M.A.v.B., M.J.P.v.O., M.A.A.v.W.) Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands. (E.W.v.Z.) Department of Neurology Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands (F.H.B.M.S., C.J.M.K.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Although evidence accumulates that the cerebellum is involved in cerebral amyloid angiopathy (CAA), cerebellar superficial siderosis is not considered to be a disease marker. The objective of this study is to investigate cerebellar superficial siderosis frequency and its relation to hemorrhagic magnetic resonance imaging markers in patients with sporadic and Dutch-type hereditary CAA and patients with deep perforating arteriopathy–related intracerebral hemorrhage.Methods:We recruited patients from 3 prospective 3 Tesla magnetic resonance imaging studies and scored siderosis and hemorrhages. Cerebellar siderosis was identified as hypointense linear signal loss (black) on susceptibility-weighted or T2*-weighted magnetic resonance imaging which follows at least one folia of the cerebellar cortex (including the vermis).Results:We included 50 subjects with Dutch-type hereditary CAA, (mean age 50 years), 45 with sporadic CAA (mean age 72 years), and 43 patients with deep perforating arteriopathy–related intracerebral hemorrhage (mean age 54 years). Cerebellar superficial siderosis was present in 5 out of 50 (10% [95% CI, 2–18]) patients with Dutch-type hereditary CAA, 4/45 (9% [95% CI, 1–17]) patients with sporadic CAA, and 0 out of 43 (0% [95% CI, 0–8]) patients with deep perforating arteriopathy–related intracerebral hemorrhage. Patients with cerebellar superficial siderosis had more supratentorial lobar (median number 9 versus 2, relative risk, 2.9 [95% CI, 2.5–3.4]) and superficial cerebellar macrobleeds (median number 2 versus 0, relative risk, 20.3 [95% CI, 8.6–47.6]) compared with patients without the marker. The frequency of cortical superficial siderosis and superficial cerebellar microbleeds was comparable.Conclusions:We conclude that cerebellar superficial siderosis might be a novel marker for CAA.
      Citation: Stroke
      PubDate: 2021-09-20T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.035019
       
  • Impact of Prior Antiplatelet Therapy on Outcomes After Endovascular
           Therapy for Acute Stroke: Endovascular Treatment in Ischemic Stroke
           Registry Results

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      Authors: Marie Couture Stephanos Finitsis Gaultier Marnat Sébastien Richard Romain Bourcier Pacôme Constant-dits-Beaufils Cyril Dargazanli Caroline Arquizan Mikaël Mazighi Raphaël Blanc François Eugène Stéphane Vannier Laurent Spelle Christian Denier Emmanuel Touzé Charlotte Barbier Suzana Saleme Francisco Macian Charlotte Rosso Frédéric Clarençon Olivier Naggara Guillaume Turc Ozlem Ozkul-Wermester Chrysanthi Papagiannaki Alain Viguier Christophe Cognard Anthony Lebras Sarah Evain Valérie Wolff Raoul Pop Serge Timsit Jean-Christophe Gentric Frédéric Bourdain Louis Veunac Bertrand Lapergue Arturo Consoli Benjamin Gory Igor Sibon Department of Neurology; Stroke Center, University Hospital of Bordeaux, France. (M.C., I.S.) Department of Diagnostic Interventional Neuroradiology, Versailles Saint-Quentin en Yvelines University, Suresnes, France. (A.C.) , for the ETIS Registry Investigators Michel Piotin Hocine Redjem Simon Escalard Jean-Philippe Dessilles François Delvoye Stanislas Smajda Benjamin Maier Hebert Solène Mikael Obadia Candice Sabben Pierre Seners Igor Raynouard Ovide Corabianu Thomas de Broucker Eric Manchon Guillaume Taylor Malek Ben Maacha Laurie-Anne Thion Augustin Lecler Julien Savatovsjy Adrien Wang Serge Evrard Maya Tchikviladze Nadia Ajili David WeisenburgerLile Lucas Gorza Géraldine Buard Oguzhan Coskun Federico Di Maria Georges Rodesh Sergio Zimatore Morgan Leguen Julie Gratieux Fernando Pico Haja Rakotoharinandrasana Philippe Tassan Roxanna Poll Sylvie Marinier Florent Gariel Xavier Barreau Jérôme Berge Patrice Menegon Ludovic Lucas Stéphane Olindo Pauline Renou Sharmila Sagnier Mathilde Poli Sabrina Debruxelles François Rouanet Thomas Tourdias Jean-Sebastien Liegey Pierre Briau Nicolas Pangon Lili Detraz Benjamin Daumas-Duport Pierre-Louis Alexandre Monica Roy Cédric Lenoble Hubert Desal Benoît Guillon Solène de Gaalon Cécile Preterre Serge Bracard René Anxionnat Marc Braun Anne-Laure Derelle Liang Liao Romain Tonnelet François Liao Emmanuelle Zhu Sophie Schmitt Sébastien Planel Lisa Richard Gioia Humbertjean Jean-Christophe Mione Nolwenn Lacour Gérard Riou-Comte Marcela Audibert Lionel Voicu Marie Alb Madalina Reitter Agnès Brezeanu Adriana Masson Iona Tabarna Sarah Podar Fatiha Guy Fatiha Bechiri Charbel Mounayer Aymeric Rouchaud Laetitia Gimenez Alexandre Cosnard Vincent Costalat Grégory Gascou Pierre-Henri Lefèvre Imad Derraz Carlos Riquelme Nicolas Gaillard Isabelle Mourand Lucas Corti Federico Cagnazzo Adrien ter Schiphorst Jean-Christophe Ferre Hélène Raoult Thomas Ronziere Maria Lassale Christophe Paya Jean-Yves Gauvrit Clément Tracol Sophie Langnier-Lemercier, Axelle Maurice Sabrina Cochennec Mélanie Pinault Eimad Shotar Nader Sourour Stéphanie Lenck Kévin Premat Yves Samson Anne Léger Sophie Crozier Flore Baronnet Sonia Alamowitch Laure Bottin Mathon Yger Vincent Degos Olivier Chassin Vanessa Chalumeau Jildaz Caroff Olivier Chassin Laura Venditti Mariana Sarov Nicolas Legris Wagih Ben Hassen Grégoire Boulouis Christine Rodriguez-Régent Denis Trystram Basile Kerleroux Pierre Seners Valérie Domigo Catherine Lamy Julia Birchenall Clothilde Isabel François Lun Anne Christine Januel Jean-Marc Olivot Nicolas Raposo Fabrice Bonneville Jean François Albucher Lionel Calviere Jean Darcourt Guillaume Bellanger Philippe Tall Romain Schneckenburger Marion Boulanger Julien Cogez Sophie Guettier Maxime Gauberti Julien Ognard Francois Mathias Merrien. Ozlem Ozku Wermester Evelyne Massardier Aude Triquenot Margeaux Lefebvre Patricia Bernady Laurent Lagoarde-Segot Hélène Cailliez David Higue Veronique Quenardelle Valerie Lauer Roxana Gheoca Irene Pierre-Paul Remy Beaujeux Dan Mihoc Monica Manisor Julien Pottecher Alain Meyer Thiên-Nga Chamaraux-Tran Anthony Le Bras Arnaud Le Guen Norbert Nighoghossian Roberto Riva Omer Eker Francis turjman Laurent Derex Tae-Hee Cho Laura Mechtouff Anne Claire Lukaszewicz Frédéric Philippeau Serkan Cakmak Karine Blanc-Lasserre Anne-Evelyne Vallet
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The influence of prior antiplatelet therapy (APT) uses on the outcomes of patients with acute ischemic stroke treated with endovascular therapy is unclear. We compared procedural and clinical outcomes of endovascular therapy in patients on APT or not before stroke onset.Methods:We analyzed 2 groups from the ongoing prospective multicenter Endovascular Treatment in Ischemic Stroke registry in France: patients on prior APT (APT+) and patients without prior APT (APT−) treated by endovascular therapy, with and without intravenous thrombolysis. Multilevel mixed-effects logistic models including center as random effect were used to compare angiographic (rates of reperfusion at the end of procedure, procedural complications) and clinical (favorable and excellent outcome, 90-day all-cause mortality, and hemorrhagic complications) outcomes according to APT subgroups. Comparisons were adjusted for prespecified confounders (age, admission National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score, intravenous thrombolysis, and time from onset to puncture), as well as for meaningful baseline between-group differences.Results:A total of 2939 patients were analyzed, of whom 877 (29.8%) were on prior APT. Patients with prior APT were older, had more frequent vascular risk factors, cardioembolic stroke mechanism, and prestroke disability. Rates of complete reperfusion (37.9% in the APT− group versus 42.7 % in the APT+ group; aOR, 1.09 [95% CI, 0.88–1.34];P=0.41) and periprocedural complication (16.9% versus 13.3%; aOR, 0.90 [95% CI, 0.7–1.2];P=0.66) did not differ between the two groups. Symptomatic intracerebral hemorrhage (aOR, 0.93 [95% CI, 0.63–1.37];P=0.73), 3 months favorable clinical outcome (modified Rankin Scale score of 0–2; aOR, 0.98 [95% CI, 0.77–1.25];P=0.89), and mortality (aOR, 0.95 [95% CI, 0.72–1.26];P=0.76) at 90 days did not differ between the groups.Conclusions:Prior APT does not influence angiographic and functional outcomes following endovascular therapy and should not be taken into account for acute revascularization strategies.
      Citation: Stroke
      PubDate: 2021-09-20T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.034670
       
  • Quantitative Lesion Water Uptake as Stroke Imaging Biomarker: A Tool for
           Treatment Selection in the Extended Time Window'

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      Authors: Gabriel Broocks Andre Kemmling Svenja Teßarek Rosalie McDonough Lukas Meyer Tobias D. Faizy Helge Kniep Gerhard Schön Marie Teresa Nawka Sarah Elsayed Noel van Horn Bastian Cheng Götz Thomalla Jens Fiehler Uta Hanning Department of Diagnostic; Epidemiology, University Medical Center Hamburg-Eppendorf, Germany. (G.S.) Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany. (G.T.) Department of Neuroradiology, University Hospital Schleswig-Holstein, Lübeck, Germany (A.K.). Department of Neuroradiology, University Hospital Marburg, Germany (A.K.). Department of Neuroradiology, Westpfalzklinikum, Kaiserslautern, Germany (T.D.F.). Department of Radiology (S.T.) Lüneburg Medical Center, Germany (G.S.). Department of Radiology, Stanford University (B.C., G.T., T.D.F.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Patients presenting in the extended time window may benefit from mechanical thrombectomy. However, selection for mechanical thrombectomy in this patient group has only been performed using specialized image processing platforms, which are not widely available. We hypothesized that quantitative lesion water uptake calculated in acute stroke computed tomography (CT) may serve as imaging biomarker to estimate ischemic lesion progression and predict clinical outcome in patients undergoing mechanical thrombectomy in the extended time window.Methods:All patients with ischemic anterior circulation stroke presenting within 4.5 to 24 hours after symptom onset who received initial multimodal CT between August 2014 and March 2020 and underwent mechanical thrombectomy were analyzed. Quantitative lesion net water uptake was calculated from the admission CT. Prediction of clinical outcome was assessed using univariable receiver operating characteristic curve analysis and logistic regression analyses.Results:One hundred two patients met the inclusion criteria. In the multivariable logistic regression analysis, net water uptake (odds ratio, 0.78 [95% CI, 0.64–0.95],P=0.01), age (odds ratio, 0.94 [95% CI, 0.88–0.99];P=0.02), and National Institutes of Health Stroke Scale (odds ratio, 0.88 [95% CI, 0.79–0.99],P=0.03) were significantly and independently associated with favorable outcome (modified Rankin Scale score ≤1), adjusted for degree of recanalization and Alberta Stroke Program Early CT Score. A multivariable predictive model including the above parameters yielded the highest diagnostic ability in the classification of functional outcome, with an area under the curve of 0.88 (sensitivity 92.3%, specificity 82.9%).Conclusions:The implementation of quantitative lesion water uptake as imaging biomarker in the diagnosis of patients with ischemic stroke presenting in the extended time window might improve clinical prognosis. Future studies could test this biomarker as complementary or even alternative tool to CT perfusion.
      Citation: Stroke
      PubDate: 2021-09-20T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.033025
       
  • Platelet Function Testing Is Required for Intracranial Stent Placement

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      Authors: René Chapot Department of Intracranial Endovascular Therapy; Alfried Krupp Hospital, Essen, Germany.
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-09-20T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.036457
       
  • Reporting of Results by Sex in Randomized Controlled Trials of Acute
           Stroke Therapies (2010–2020)

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      Authors: Julia Pudar Brent Strong Virginia J. Howard Mathew J. Reeves Department of Epidemiology; Biostatistics, College of Human Medicine, Michigan State University, East Lansing (J.P., B.S., M.J.R.). Department of Epidemiology, University of Alabama at Birmingham (V.J.H.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:When reporting primary results from randomized controlled trials, recommendations include reporting results by sex. We reviewed the reporting of results by sex in contemporary acute stroke randomized controlled trials.Methods:We searched MEDLINE for articles reporting the primary results of phase 2 or 3 stroke randomized controlled trials published between 2010 and June 2020 in one of nine major clinical journals. Eligible trials were restricted to those with a therapeutic intervention initiated within one month of stroke onset. Of primary interest was the reporting of results by sex for the primary outcome. We performed bivariate analyses using Fisher exact tests to identify study-level factors associated with reporting by sex and investigated temporal trends using an exact test for trend.Results:Of the 115 studies identified, primary results were reported by sex in 37% (n=42). Reporting varied significantly by journal, with theNew England Journal of Medicine(61%) andLancetjournals (40%) having the highest rates (P=0.03). Reporting also differed significantly by geographic region (21% Europe versus 48% Americas,P=0.03), trial phase (13% phase 2 versus 40% phase 3,P=0.05), and sample size (24% <250 participants versus 61% >750 participants,P<0.01). Although not statistically significant (P=0.11), there was a temporal trend in favor of greater reporting among later publications (25% 2010–2012 versus 48% 2019–2020).Conclusions:Although reporting of primary trial results by sex improved from 2010 to 2020, the prevalence of reporting in major journals is still low. Further efforts are required to encourage journals and authors to comply with current reporting recommendations.
      Citation: Stroke
      PubDate: 2021-09-16T09:00:25Z
      DOI: 10.1161/STROKEAHA.120.034099
       
  • Baseline Characteristics of Patients With Cavernous Angiomas With
           Symptomatic Hemorrhage in Multisite Trial Readiness Project

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      Authors: Helen Kim Kelly D. Flemming Jeffrey A. Nelson Avery Lui Jennifer J. Majersik Michael Dela Cruz Joseph Zabramski Odilette Trevizo Giuseppe Lanzino Atif Zafar Michel Torbey Marc C. Mabray Myranda Robinson Jared Narvid Janine Lupo Richard E. Thompson Daniel F. Hanley Nichol McBee Kevin Treine Noeleen Ostapkovich Agnieszka Stadnik Kristina Piedad Nicholas Hobson Timothy Carroll Abdallah Shkoukani Julián Carrión-Penagos Carolina Mendoza-Puccini James I. Koenig Issam Awad Center for Cerebrovascular Research; Department of Anesthesia Stroke, Bethesda, MD. (J.I.K.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Brain cavernous angiomas with symptomatic hemorrhage (CASH) have a high risk of neurological disability from recurrent bleeding. Systematic assessment of baseline features and multisite validation of novel magnetic resonance imaging biomarkers are needed to optimize clinical trial design aimed at novel pharmacotherapies in CASH.Methods:This prospective, multicenter, observational cohort study included adults with unresected, adjudicated brain CASH within the prior year. Six US sites screened and enrolled patients starting August 2018. Baseline demographics, clinical and imaging features, functional status (modified Rankin Scale and National Institutes of Health Stroke Scale), and patient quality of life outcomes (Patient-Reported Outcomes Measurement Information System-29 and EuroQol-5D) were summarized using descriptive statistics. Patient-Reported Outcomes Measurement Information System-29 scores were standardized against a reference population (mean 50, SD 10), and one-samplettest was performed for each domain. A subgroup underwent harmonized magnetic resonance imaging assessment of lesional iron content with quantitative susceptibility mapping and vascular permeability with dynamic contrast-enhanced quantitative perfusion.Results:As of May 2020, 849 patients were screened and 110 CASH cases enrolled (13% prevalence of trial eligible cases). The average age at consent was 46±16 years, 53% were female, 41% were familial, and 43% were brainstem lesions. At enrollment, ≥90% of the cohort had independent functional outcome (modified Rankin Scale score ≤2 and National Institutes of Health Stroke Scale score <5). However, perceived health problems affecting quality of life were reported in >30% of patients (EuroQol-5D). Patients had significantly worse Patient-Reported Outcomes Measurement Information System-29 scores for anxiety (P=0.007), but better depression (P=0.002) and social satisfaction scores (P=0.012) compared with the general reference population. Mean baseline quantitative susceptibility mapping and permeability of CASH lesion were 0.45±0.17 ppm and 0.39±0.31 mL/100 g per minute, respectively, which were similar to historical CASH cases and consistent across sites.Conclusions:These baseline features will aid investigators in patient stratification and determining the most appropriate outcome measures for clinical trials of emerging pharmacotherapies in CASH.
      Citation: Stroke
      PubDate: 2021-09-16T09:00:25Z
      DOI: 10.1161/STROKEAHA.120.033487
       
  • Phenotypes of Chronic Covert Brain Infarction in Patients With First-Ever
           Ischemic Stroke: A Cohort Study

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      Authors: Jan Vynckier Johannes Kaesmacher Joanna Marguerite Wardlaw Laurent Roten Morin Beyeler Nebiyat Filate Belachew Lorenz Grunder David Julian Seiffge Simon Jung Jan Gralla Tomas Dobrocky Mirjam Rachel Heldner Ulrike Prange Martina Béatrice Goeldlin Marcel Arnold Urs Fischer Thomas Raphael Meinel Department of Neurology; Inselspital, Bern University Hospital, University of Bern, Switzerland. (J.K., N.F.B., L.G., J.G., T.D.) Department of Cardiology, University of Edinburgh, United Kingdom. (L.R.) Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom. (J.W.) UK Dementia Research Institute, University of Edinburgh, United Kingdom. (J.W.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The aim of this study was to assess the rate of chronic covert brain infarctions (CBIs) in patients with acute ischemic stroke (AIS) and to describe their phenotypes and diagnostic value.Methods:This is a single-center cohort study including 1546 consecutive patients with first-ever AIS on magnetic resonance imaging imaging from January 2015 to December 2017. The main study outcomes were CBI phenotypes, their relative frequencies, location, and association with vascular risk factors.Results:Any CBI was present in 574/1546 (37% [95% CI, 35%–40%]) of patients with a total of 950 CBI lesions. The most frequent locations of CBI were cerebellar in 295/950 (31%), subcortical supratentorial in 292/950 (31%), and cortical in 213/950 (24%). CBI phenotypes included lacunes (49%), combined gray and white matter lesions (30%), gray matter lesions (13%), and large subcortical infarcts (7%). Vascular risk profile and white matter hyperintensities severity (19% if no white matter hyperintensity, 63% in severe white matter hyperintensity,P<0.001) were associated with presence of any CBI. Atrial fibrillation was associated with cortical lesions (adjusted odds ratio, 2.032 [95% CI, 1.041–3.967]). Median National Institutes of Health Stroke Scale scores on admission were higher in patients with an embolic CBI phenotype (median National Institutes of Health Stroke Scale, 5 [2–10],P=0.025).Conclusions:CBIs were present in more than a third of patients with first AIS. Their location and phenotypes as determined by MRI were different from previous studies using computed tomography imaging. Among patients suffering from AIS, those with additional CBI represent a vascular high-risk subgroup and the association of different phenotypes of CBIs with differing risk factor profiles potentially points toward discriminative AIS etiologies.
      Citation: Stroke
      PubDate: 2021-09-16T09:00:25Z
      DOI: 10.1161/STROKEAHA.121.034347
       
  • Mucormycosis Epidemic and Stroke in India During the COVID-19 Pandemic

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      Authors: M.V. Padma Srivastava Venugopalan Y. Vishnu Awadh Kishor Pandit Department of Neurology; All India Institute of Medical Sciences (AIIMS), New Delhi.
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-09-16T09:00:25Z
      DOI: 10.1161/STROKEAHA.121.036626
       
  • White Matter Hyperintensity Burden and Collateral Circulation in Large
           Vessel Occlusion Stroke

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      Authors: Imad Derraz Mohamed Abdelrady Nicolas Gaillard Raed Ahmed Federico Cagnazzo Cyril Dargazanli Pierre-Henri Lefevre Lucas Corti Carlos Riquelme Isabelle Mourand Gregory Gascou Alain Bonafe Caroline Arquizan Vincent Costalat Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France. (I.D; M.A, R.A, F.C, C.D, P.-H.L, C.R, G.G, A.B, V.C.) Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France. (N.G, L.C, I.M, C.A.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:White matter hyperintensity (WMH), a marker of chronic cerebral small vessel disease, might impact the recruitment of leptomeningeal collaterals. We aimed to assess whether the WMH burden is associated with collateral circulation in patients treated by endovascular thrombectomy for anterior circulation acute ischemic stroke.Methods:Consecutive acute ischemic stroke due to anterior circulation large vessel occlusion and treated with endovascular thrombectomy from January 2015 to December 2017 were included. WMH volumes (periventricular, deep, and total) were assessed by a semiautomated volumetric analysis on fluid-attenuated inversion recovery–magnetic resonance imaging. Collateral status was graded on baseline catheter angiography using the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grading system (good when ≥3). We investigated associations of WMH burden with collateral status.Results:A total of 302 patients were included (mean age, 69.1±19.4 years; women, 55.6%). Poor collaterals were observed in 49.3% of patients. Median total WMH volume was 3.76 cm3(interquartile range, 1.09–11.81 cm3). The regression analyses showed no apparent relationship between WMH burden and the collateral status measured at baseline angiography (adjusted odds ratio, 0.987 [95% CI, 0.971–1.003];P=0.12).Conclusions:WMH burden exhibits no overt association with collaterals in large vessel occlusive stroke.
      Citation: Stroke
      PubDate: 2021-09-14T09:00:04Z
      DOI: 10.1161/STROKEAHA.120.031736
       
  • Effect of Hispanic Status in Mechanical Thrombectomy Outcomes After
           Ischemic Stroke: Insights From STAR

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      Authors: Joshua D. Burks Stephanie H. Chen Evan M. Luther Eyad Almallouhi Sami Al Kasab Pascal M. Jabbour Stacey Q. Wolfe Kyle M. Fargen Adam S. Arthur Nitin Goyal Isabel Fragata Ilko Maier Charles Matouk Jonathan Grossberg Peter Kan Clemens Schirmer R. Webster Crowley William Ares Christopher S. Ogilvy Ansaar T. Rai Michael R. Levitt Maxim Mokin Waldo Guerrero Min S. Park Justin Mascitelli Albert Yoo Richard W. Williamson Andrew Grande Roberto Crosa Sharon Webb Marios Psychogios Eric C. Peterson Dileep R. Yavagal Alejandro M. Spiotta Robert M. Starke Department of Neurosurgery; University of Miami, FL (J.D.B., S.H.C., E.M.L., E.C.P., D.R.Y., R.M.S.). Department of Neurosurgery, Medical University of South Carolina, Charleston (E.A., S.A.K., A.M.S.). Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (P.M.J.). Department of Neurosurgery, Wake Forrest School of Medicine, Winston-Salem, NC (S.Q.W., K.M.F.). Department of Neurosurgery, Semmes-Murphey Neurologic Spine Clinic, Memphis, TN. (N.G.) Department of Neuroradiology, Hospital Sao Jose Centro Hospitalar Lisboa Central, Lisboa, Portugal (I.F.). Department of Neurology, University Medical Center Gottingen, Germany (I.M.). Department of Neurosurgery, Yale University, New Haven, CT (C.M.). Department of Neurosurgery, Emory University, Atlanta, GA (J.G.). Department of Neurosurgery, Baylor School of Medicine, Houston, TX (P.K.). Department of Neurosurgery, Geisinger Health System, Wilkes-Barre, PA (C.S.). Department of Neurosurgery, Rush University, Chicago, IL (R.W.C.). Department of Neurosurgery, NorthShore University Health System, Evanston, IL (W.A.). Department of Neurosurgery, Beth Isreal Deaconess Hospital, Boston, MA (C.S.O.). Department of Neuroradiology, University of West Virginia, Morgantown (A.T.R.). Department of Neurosurgery, University of Texas Health Sciences Center at San Antonio (J.M.). Department of Neurosurgery, University of Washington, Seattle (M.R.L.). Department of Neurosurgery, University of South Florida, Tampa (M.M., W.G.). Department of Neurosurgery, University of Virginia, Charlottesville (M.S.P.). Texas Stroke Institute, Fort Worth (A.Y.). Department of Neurosurgery, Allegheny Health Network, Pittsburgh, PA (R.W.W.). Department of Neurosurgery, University of Minnesota, Minneapolis (A.G.). Department of Neurosurgery Centro Endovascular Neurologico Medica Uruguaya Montevideo, Uruguay (R.C.). Department of Neurosurgery, Bon Secours Health System, Greenville, SC (S.W.). Department of Radiology, University Hospital Basel, Switzerland (M.P.). , on behalf of STAR Investigators Daniel Raper Patrick Brown M. Reid Gooch Nabeel Herial Ajith Thomas Justin Moore Felipe Albuquerque Louis Kim Melanie Walker Michael Chen Stephan Munich Daniel Hoit Violiza Inoa-Acosta Christopher Nickele Lucas Elijovich Fernanda Rodriguez-Erazú Jan Liman Michael Cawley Gustavo Pradilla Brian Howard Brian Walcott Zeguang Ren Ryan Hebert Joāo Reis Jaime Pamplona Rui Carvalho Mariana Baptista Ana Nunes Russell Cerejo Ashis Tayal Parita Bhuva Paul Hansen Norman Ajibove Alex Brehm Jonathan Lena Kimberly Kicielinski
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Epidemiological studies have shown racial and ethnic minorities to have higher stroke risk and worse outcomes than non-Hispanic Whites. In this cohort study, we analyzed the STAR (Stroke Thrombectomy and Aneurysm Registry) database, a multi-institutional database of patients who underwent mechanical thrombectomy for acute large vessel occlusion stroke to determine the relationship between mechanical thrombectomy outcomes and race.Methods:Patients who underwent mechanical thrombectomy between January 2017 and May 2020 were analyzed. Data included baseline characteristics, vascular risk factors, complications, and long-term outcomes. Functional outcomes were assessed with respect to Hispanic status delineated as non-Hispanic White (NHW), non-Hispanic Black (NHB), or Hispanic patients. Multivariate analysis was performed to identify variables associated with unfavorable outcome or modified Rankin Scale ≥3 at 90 days.Results:Records of 2115 patients from the registry were analyzed. Median age of Hispanic patients undergoing mechanical thrombectomy was 60 years (72–84), compared with 63 years (54–74) for NHB, and 71 years (60–80) for NHW patients (P<0.001). Hispanic patients had a higher incidence of diabetes (41%;P<0.001) and hypertension (82%;P<0.001) compared with NHW and NHB patients. Median procedure time was shorter in Hispanics (36 minutes) compared to NHB (39 minutes) and NHW (44 minutes) patients (P<0.001). In multivariate analysis, Hispanic patients were less likely to have favorable outcome (odds ratio, 0.502 [95% CI, 0.263–0.959]), controlling for other significant predictors (age, admission National Institutes Health Stroke Scale, onset to groin time, number of attempts, procedure time).Conclusions:Hispanic patients are less likely to have favorable outcome at 90 days following mechanical thrombectomy compared to NHW or NHB patients. Further prospective studies are required to validate our findings.
      Citation: Stroke
      PubDate: 2021-09-14T09:00:04Z
      DOI: 10.1161/STROKEAHA.120.033326
       
  • Multiple Chronic Conditions Explain Ethnic Differences in Functional
           Outcome Among Patients With Ischemic Stroke

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      Authors: Xiaqing Jiang Lewis B. Morgenstern Christine T. Cigolle Lu Wang Edward S. Claflin Lynda D. Lisabeth Department of Epidemiology; School of Public Health, University of Michigan. (X.J., L.B.M., L.D.L.) Department of Biostatistics, School of Public Health, University of Michigan. (L.W.) Stroke Program, University of Michigan Medical School. (L.B.M., E.S.C., L.D.L.) Department of Family Medicine Clinical Center, VA Ann Arbor Healthcare System (C.T.C.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Mexican Americans (MAs) have worse stroke outcomes and a different profile of multiple chronic conditions (MCC) compared with non-Hispanic White people. MCC has implications for stroke treatment, complications, and poststroke care, which impact poststroke functional outcome (FO). We sought to assess the contribution of MCC to the ethnic difference in FO at 90 days between MAs and non-Hispanic White people.Methods:In a prospective cohort of ischemic stroke patients (2008–2016) from Nueces County, Texas, data were collected from patient interviews, medical records, and hospital discharge data. MCC was assessed using a stroke-specific and function-relevant index (range, 0–35; higher scores greater MCC burden). Poststroke FO was measured by an average score of 22 activities of daily living (ADLs) and instrumental ADLs at 90 days (range, 1–4; higher scores worse FO). The contribution of MCC to the ethnic difference in FO was assessed using Tobit regression. Effect modification by ethnicity was examined.Results:Among the 896 patients, 70% were MA and 51% were women. Mean age was 68±12.2 years; 33% of patients were dependent in ADL/instrumental ADLs (FO score >3, representing a lot of difficulty with ADL/instrumental ADLs) at 90 days. MAs had significantly higher age-adjusted MCC burden compared with non-Hispanic White people. Patients with high MCC score (at the 75th percentile) on average scored 0.70 points higher in the FO score (indicating worse FO) compared with those with low MCC score (at the 25th percentile) after adjusting for age, initial National Institutes of Health Stroke Scale, and sociodemographic factors. MCC explained 19% of the ethnic difference in FO, while effect modification by ethnicity was not statistically significant.Conclusions:MAs had a higher age-adjusted MCC burden, which partially explained the ethnic difference in FO. The prevention and treatment of MCC could potentially mitigate poststroke functional impairment and lessen ethnic disparities in stroke outcomes.
      Citation: Stroke
      PubDate: 2021-09-14T09:00:04Z
      DOI: 10.1161/STROKEAHA.120.032595
       
  • Temporal Profile of Pneumonia After Stroke

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      Authors: Jeroen C. de Jonge Diederik van de Beek Patrick Lyden Marian C. Brady Philip M. Bath H. Bart van der Worp Department of Neurology; Allied Health Professions Research Unit, Glasgow Caledonian University, United Kingdom (M.C.B.). Stroke Trials Unit, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, United Kingdom (P.M.B.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The occurrence of pneumonia after stroke is associated with a higher risk of poor outcome or death. We assessed the temporal profile of pneumonia after stroke and its association with poor outcome at several time points to identify the most optimal period for testing pneumonia prevention strategies.Methods:We analyzed individual patient data stored in the VISTA (Virtual International Stroke Trials Archive) from randomized acute stroke trials with an inclusion window up to 24 hours after stroke onset and assessed the occurrence of pneumonia in the first 90 days after stroke. Adjusted odds ratios and hazard ratios were calculated for the association between pneumonia and poor outcome and death by means of logistic and Cox proportional hazard regression, respectively, at different times of follow-up.Results:Of 10 821 patients, 1017 (9.4%) had a total of 1076 pneumonias. Six hundred eighty-nine (64.0%) pneumonias occurred in the first week after stroke. The peak incidence was on the third day and the median time of onset was 4.0 days after stroke (interquartile range, 2–12). The presence of a pneumonia was associated with an increased risk of poor outcome (adjusted odds ratio, 4.8 [95% CI, 3.8–6.1]) or death (adjusted hazard ratio, 4.1 [95% CI, 3.7–4.6]). These associations were present throughout the 90 days of follow-up.Conclusions:Two out of 3 pneumonias in the first 3 months after stroke occur in the first week, with a peak incidence on the third day. The most optimal period to assess pneumonia prevention strategies is the first 4 days after stroke. However, pneumonia occurring later was also associated with poor functional outcome or death.
      Citation: Stroke
      PubDate: 2021-09-14T09:00:04Z
      DOI: 10.1161/STROKEAHA.120.032787
       
  • Arterial Spin Labeling for the Etiological Workup of Intracerebral
           Hemorrhage in Children

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      Authors: Jean François Hak Grégoire Boulouis Basile Kerleroux Sandro Benichi Sarah Stricker Florent Gariel Lorenzo Garzelli Philippe Meyer Manoelle Kossorotoff Nathalie Boddaert Vincent Vidal Nadine Girard Volodia Dangouloff Ros Francis Brunelle Thomas Blauwblomme Olivier Naggara Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, AP-HP, University hospital Necker-Enfants-malades, Paris, France. (J.F.H; G.B, B.K, F.G, L.G, N.B, V.D.R, F.B, O.N.) the Department of Pediatric Neurosurgery, Institut Imagine, INSERM UMR 1163, AP-HP, University hospital Necker-Enfants-malades, Paris, France. (S.B, S.S, T.B.) Pediatric Neuro ICU, AP-HP, University hospital Necker-Enfants-malades, Paris, France. (P.M.) French Center for Pediatric Stroke, INSERM U894, AP-HP, University hospital Necker-Enfants-malades, Paris, France. (M.K, T.B, O.N.) Department of Pediatric Neurology, AP-HP, University hospital Necker-Enfants-malades, Paris, France. (M.K.) Université de Paris, INSERM UMR 1266 IMA-BRAIN, Department of Interventional Neuroradiology, GHU Paris, France (J.F.H, G.B, B.K, O.N.). Department of Neuroradiology, University Hospital of Bordeaux, France (F.G.). Department of Radiology, University Hospital La Timone Hospital, AP-HM, Marseille, France. (V.V.) Department of Neuroradiology, University Hospital La Timone Hospital, AP-HM, Marseille, France. (N.G.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Pediatric nontraumatic intracerebral hemorrhage accounts for half of stroke in children. Early diagnostic of the causative underlying lesion is the first step toward prevention of hemorrhagic recurrence. We aimed to investigate the performance of arterial spin labeling sequence (ASL) in the acute phase etiological workup for the detection of an arteriovenous shunt (AVS: including malformation and fistula), the most frequent cause of pediatric nontraumatic intracerebral hemorrhage.Methods:Children with a pediatric nontraumatic intracerebral hemorrhage between 2011 and 2019 enrolled in a prospective registry were retrospectively included if they had undergone ASL-magnetic resonance imaging before any etiological treatment. ASL sequences were reviewed using cerebral blood flow maps by 2 raters for the presence of an AVS. The diagnostic performance of ASL was compared with admission computed tomography angiography, other magnetic resonance imaging sequences including contrast-enhanced sequences and subsequent digital subtraction angiography.Results:A total of 121 patients with pediatric nontraumatic intracerebral hemorrhage were included (median age, 9.9 [interquartile range, 5.8–13]; male sex 48.8%) of whom 76 (63%) had a final diagnosis of AVS. Using digital subtraction angiography as an intermediate reference, visual ASL inspection had a sensitivity and a specificity of, respectively, 95.9% (95% CI, 88.5%–99.1%) and 79.0% (95% CI, 54.4%–94.0%). ASL had a sensitivity, specificity, and accuracy of 90.2%, 97.2%, and 92.5%, respectively for the detection of the presence of an AVS, with near perfect inter-rater agreement (κ=0.963 [95% CI, 0.912–1.0]). The performance of ASL alone was higher than that of other magnetic resonance imaging sequences, individually or combined, and higher than that of computed tomography angiography.Conclusions:ASL has strong diagnostic performance for the detection of AVS in the initial workup of intracerebral hemorrhage in children. If our findings are confirmed in other settings, ASL may be a helpful diagnostic imaging modality for patients with pediatric nontraumatic intracerebral hemorrhage.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifiers: 3618210420, 2217698.
      Citation: Stroke
      PubDate: 2021-09-14T09:00:04Z
      DOI: 10.1161/STROKEAHA.120.032690
       
  • Outcomes of Endovascular Therapy in Patients With Prestroke Mobility
           Impairment

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      Authors: Rachel Beekman Jie-Lena Sun Brooke Alhanti Lee H. Schwamm Eric E. Smith Deepak L. Bhatt Ying Xian Shreyansh Shah Barbara L. Lytle Gregg C. Fonarow Kevin N. Sheth Department of Neurology; Yale School of Medicine, New Haven, CT (R.B., K.N.S.). Department of Biostatistics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.-L.S., B.A., Y.X., S.S., B.L.L.). Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.). Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.). Department of Cardiovascular Medicine, Brigham Vascular Center, Harvard Medical School, Boston, MA (D.L.B.). Division of Cardiology/Department of Medicine, Ronald-Regan UCLA Medical Center, Los Angeles, CA (G.C.F.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Patients with prestroke mobility impairment (PSMI) were excluded from endovascular clinical trials. There are limited data regarding safety and outcomes of endovascular thrombectomy in this population. We used a large, national data set (Get With The Guidelines–Stroke) to evaluate the safety and outcomes of endovascular thrombectomy in patients with PSMI.Methods:We included patients who underwent endovascular thrombectomy in the Get With The Guidelines–Stroke registry between 2015 and 2019. PSMI was defined as the inability to ambulate independently. Generalized estimating equations for logistic regression models were used to evaluate the association between PSMI and outcomes.Results:Of 56 762 patients treated with endovascular thrombectomy, 2919 (5.14%) had PSMI. PSMI was not associated with symptomatic intracranial hemorrhage (6.0% versus 5.4%;P=0.979). In-hospital death or discharge to hospice occurred in 32.3% of patients with PSMI versus 17.5% without PSMI (adjusted odds ratio, 1.45 [1.32–1.58]).Conclusions:While procedural adverse outcomes were no higher in patients with PSMI, further study is necessary to determine clinical benefit in this population.
      Citation: Stroke
      PubDate: 2021-09-14T09:00:04Z
      DOI: 10.1161/STROKEAHA.121.034464
       
  • Cilostazol for Secondary Stroke Prevention: History, Evidence,
           Limitations, and Possibilities

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      Authors: Adam de Havenon Kevin N. Sheth Tracy E. Madsen Karen C. Johnston Tanya N. Turan Kazunori Toyoda Jordan J. Elm Joanna M. Wardlaw S. Claiborne Johnston Olajide A. Williams Ashkan Shoamanesh Maarten G. Lansberg Department of Neurology; University of Utah (A.d.H.). Department of Neurology, Yale University (K.N.S.). Department of Emergency Medicine, Brown University (T.E.M.). Department of Neurology, University of Virginia (K.C.J.). Department of Neurology, Medical University of South Carolina (T.N.T., J.J.E.). Department of Cerebrovascular Medicine, National Cerebral Cardiovascular Center, Japan (K.T.). Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.). Dell Medical School (S.C.J.). Department of Neurology, Columbia University (O.A.W.). Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.). Department of Neurology, Stanford University (M.G.L.).
      Abstract: Stroke, Ahead of Print.
      Cilostazol is a PDE3 (phosphodiesterase III) inhibitor with a long track record of safety that is Food and Drug Administration and European Medicines Agency approved for the treatment of claudication in patients with peripheral arterial disease. In addition, cilostazol has been approved for secondary stroke prevention in several Asian countries based on trials that have demonstrated a reduction in stroke recurrence among patients with noncardioembolic stroke. The onset of benefit appears after 60 to 90 days of treatment, which is consistent with cilostazol’s pleiotropic effects on platelet aggregation, vascular remodeling, blood flow, and plasma lipids. Cilostazol appears safe and does not increase the risk of major bleeding when given alone or in combination with aspirin or clopidogrel. Adverse effects such as headache, gastrointestinal symptoms, and palpitations, however, contributed to a 6% increase in drug discontinuation among patients randomized to cilostazol in a large secondary stroke prevention trial (CSPS.com [Cilostazol Stroke Prevention Study for Antiplatelet Combination]). Due to limitations of prior trials, such as open-label design, premature trial termination, large loss to follow-up, lack of functional or cognitive outcome data, and exclusive enrollment in Asia, the existing trials have not led to a change in clinical practice or guidelines in Western countries. These limitations could be addressed by a double-blind placebo-controlled randomized trial conducted in a broader population. If positive, it would increase the evidence in support of long-term treatment with cilostazol for secondary prevention in the millions of patients worldwide who have experienced a noncardioembolic ischemic stroke.
      Citation: Stroke
      PubDate: 2021-09-14T09:00:04Z
      DOI: 10.1161/STROKEAHA.121.035002
       
  • Studying Stroke Thrombus Composition After Thrombectomy: What Can We
           Learn'

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      Authors: Senna Staessens Olivier François Waleed Brinjikji Karen M. Doyle Peter Vanacker Tommy Andersson Simon F. De Meyer Laboratory for Thrombosis Research; KU Leuven Campus Kulak Kortrijk, Belgium (S.S., S.F.D.M.). Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium. (O.F., T.A.) Department of Neurology, AZ Groeninge, Kortrijk, Belgium. (P.V.) Department of Radiology, Mayo Clinic, Rochester, MN (W.B.). CÚRAM-Centre for Research in Medical Devices, National University of Ireland Galway, Ireland (K.M.D.). Department of Neurology, University Hospitals Antwerp, Belgium (P.V.). Department of Translational Neuroscience, University of Antwerp, Belgium (P.V.). Department of Neuroradiology, Karolinska University Hospital Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.).
      Abstract: Stroke, Ahead of Print.
      The composition of ischemic stroke thrombi has gained an increasing amount of interest in recent years. The implementation of endovascular procedures in standard stroke care has granted researchers the unique opportunity to examine patient thrombus material. Increasing evidence indicates that stroke thrombi are complex and heterogenous, consisting of various biochemical (eg, fibrin, von Willebrand factor, and neutrophil extracellular traps) and cellular (eg, red blood cells, platelets, leukocytes, and bacteria) components. This complex composition may explain therapeutic limitations and also offer novel insights in several aspects of stroke management. Better understanding of thrombus characteristics could, therefore, potentially lead to improvements in the management of patients with stroke. In this review, we provide a comprehensive overview of the lessons learned by examining stroke thrombus composition after endovascular thrombectomy and its potential relevance for thrombectomy success rates, thrombolysis, clinical outcomes, stroke etiology, and radiological imaging.
      Citation: Stroke
      PubDate: 2021-09-14T09:00:04Z
      DOI: 10.1161/STROKEAHA.121.034289
       
  • Vascular Brain Health

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      Authors: Christopher L.H. Chen Tatjana Rundek Memory Aging; Cognition Centre, National University Health System, Yong Loo Lin School of Medicine, National University of Singapore (C.L.H.C.). Department of Neurology, Evelyn F. McKnight Brain Institute, Miller School of Medicine, University of Miami (T.R.).
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-09-14T09:00:04Z
      DOI: 10.1161/STROKEAHA.121.033450
       
  • Serum Sphingosine-1-Phosphate Levels Are Associated With Severity and
           Outcome in Patients With Cerebral Ischemia

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      Authors: Edzard Schwedhelm Laura Schwieren Steffen Tiedt Mirjam von Lucadou Nils-Ole Gloyer Rainer Böger Tim Magnus Guenter Daum Götz Thomalla Christian Gerloff Chi-un Choe Institute of Clinical Pharmacology; Vascular Center Hamburg-Eppendorf, Germany (G.D.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The aim of this study was to examine whether sphingosine-1-phosphate (S1P) levels in patients with acute stroke are associated with stroke severity and outcome.Methods:In a prospective stroke cohort (MARK-STROKE), 374 patients with acute ischemic stroke or transient ischemic attack were enrolled (mean age: 67.9±13.0 years, sex: 64.7% male), and serum-S1P at admission was analyzed with tandem mass spectrometry. In addition to cross-sectional analyses, 79 adverse events (death, stroke, myocardial infarction, rehospitalization) were recorded in 270 patients during follow-up. Regression analyses were adjusted for age, sex, low-density lipoprotein cholesterol, and vascular risk factors. Results were validated in an independent stroke cohort with 219 patients with acute ischemic stroke (CIRCULAS).Results:Low serum-S1P was associated with higher National Institutes of Health Stroke Scale score at admission and with anterior circulation nonlacunar infarcts determined by multivariate regression analyses. During a follow-up of 294±170 days, patients with S1P in the lowest tertile (<1.33 µmol/L) had more adverse events (Kaplan-Meier analysis,P=0.048 for trend). In adjusted Cox regression analysis, the lowest S1P tertile was associated with a worse outcome after stroke (hazard ratio, HR 0.51 [95% confidence interval 0.28–0.92]). Results were confirmed in an independent cohort, ie, low S1P levels were associated with higher National Institutes of Health Stroke Scale, larger infarct volumes and worse outcome after 90 days (β-coefficient: –0.03,P=0.026; β-coefficient: −0.099,P=0.009 and odds ratio 0.52 [0.28–0.96], respectively).Conclusions:Our findings imply a detrimental role of low S1P levels in acute stroke and therefore underpin the therapeutic potential of S1P-mimics.
      Citation: Stroke
      PubDate: 2021-09-09T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033414
       
  • Day-by-Day Blood Pressure Variability in the Subacute Stage of Ischemic
           Stroke and Long-Term Recurrence

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      Authors: Kenji Fukuda Ryu Matsuo Masahiro Kamouchi Fumi Kiyuna Noriko Sato Kuniyuki Nakamura Jun Hata Yoshinobu Wakisaka Tetsuro Ago Tsutomu Imaizumi Hisashi Kai Takanari Kitazono Department of Medicine; Welfare, Japan (T.I.). Department of Cardiology, Kurume University Medical Center, Japan (H.K.). , on behalf of the FSR Investigators Takao Ishitsuka Setsuro Ibayashi Kenji Kusuda Kenichiro Fujii Tetsuhiko Nagao Yasushi Okada Masahiro Yasaka Hiroaki Ooboshi Katsumi Irie Tsuyoshi Omae Kazunori Toyoda Hiroshi Nakane Hiroshi Sugimori Shuji Arakawa Jiro Kitayama Shigeru Fujimoto Shoji Arihiro Junya Kuroda Yoshihisa Fukushima Yasuhiro Kumai Noriko Makihara
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:This study aimed to determine whether variability of day-by-day blood pressure (BP) during the subacute stage of acute ischemic stroke is predictive of long-term stroke recurrence.Methods:We analyzed 7665 patients (mean±SD age: 72.9±13.1 years; women: 42.4%) hospitalized for first-ever ischemic stroke in 7 stroke centers in Fukuoka, Japan, from June 2007 to November 2018. BP was measured daily during the subacute stage (4–10 days after onset). Its mean and coefficient of variation (CV) values were calculated and divided into 4 groups according to the quartiles of these BP parameters. Patients were prospectively followed up for recurrent stroke or all-cause death. The cumulative event rate was calculated with the Kaplan-Meier method. We estimated the hazard ratios and 95% confidence intervals of the events of interest after adjusting for potential confounders and mean BP values using Cox proportional hazards models. The Fine-Gray model was also used to account for the competing risk of death.Results:With a mean (±SD) follow-up duration of 3.9±3.2 years, the rates of recurrent stroke and all-cause death were 3.9 and 9.9 per 100 patient-years, respectively. The cumulative event rates of recurrent stroke and all-cause death increased with increasing CVs of systolic BP and diastolic BP. The systolic BP CV was significantly associated with an increased risk of recurrent stroke after adjusting for multiple confounders and mean BP (hazard ratio [95% CI] for fourth quartile versus first quartile, 1.26 [1.05–1.50]); the risk of recurrent stroke also increased with an increasing systolic BP CV for nonfatal strokes (1.26 [1.05–1.51]) and when death was regarded as a competing risk (1.21 [1.02–1.45]). Similar associations were observed for the diastolic BP CV.Conclusions:Day-by-day variability of BP during the subacute stage of acute ischemic stroke was associated with an increased long-term risk of recurrent stroke.
      Citation: Stroke
      PubDate: 2021-09-09T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033751
       
  • Protective Role of Caregiver Preparedness on the Relationship Between
           Depression and Quality of Life in Stroke Dyads

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      Authors: Gianluca Pucciarelli Karen S. Lyons Antonello Petrizzo Rossella Ambrosca Silvio Simeone Rosaria Alvaro Christopher S. Lee Ercole Vellone Department of Biomedicine; Prevention, University of Rome Tor Vergata, Rome, Italy. (E.V.) Boston College, William F. Connell School of Nursing (K.S.L., C.S.L.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Depression and quality of life (QOL) have an interdependent and transactional nature in stroke survivor-caregiver dyads. While the strong relationship between depression and physical and emotional QOL in stroke survivor-caregiver dyads is well known, it is less clear if this relationship is moderated by caregiver preparedness, which could easily be targeted with interventions. In this study, we examined the moderating role of caregiver preparedness on the association between depression and QOL in stroke survivor-caregiver dyads.Methods:We used a longitudinal design with follow-ups every 3 months over a 1-year period. Considering the nonindependent nature of the data (survivors and their caregivers), we used multilevel modeling to analyze data at the dyad level. We implemented 4 longitudinal dyadic moderation models (one for each QOL domain: physical, psychological, social, and environmental) using hierarchical linear modeling.Results:A sample of 222 stroke survivor-caregiver dyads was analyzed. Stroke survivors were older (M=70.8, SD=11.9) than their caregivers (M=52.4, SD=13.1). Stroke survivors predominantly had an ischemic stroke, equally distributed by site. Caregivers were primarily female (66%), with a medium to high educational level (57%). Caregiver preparedness significantly moderated the association between survivor depression and survivor psychological (B=0.56,P<0.01) and environmental (B=0.58,P<0.01) QOL at baseline and social QOL over time (B=0.24,P<0.05). Similarly, caregiver preparedness significantly moderated the association between caregiver depression and caregiver physical (B=0.25,P<0.01) and environmental (B=0.18,P<0.05) QOL over time.Conclusions:Caregiver preparedness has a positive influence on both members of the dyad. Assessment of stroke-caregiver preparedness could be helpful to motivate clinicians to develop and implement interventions for stroke survivor-caregiver dyads.
      Citation: Stroke
      PubDate: 2021-09-09T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.034029
       
  • Treatment-Relevant Findings in Transesophageal Echocardiography After
           Stroke: A Prospective Multicenter Cohort Study

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      Authors: Götz Thomalla Mira Upneja Stephan Camen Märit Jensen Julian Schröder Ewgenia Barow Stefan Boskamp Birgit Ostermeier Sandra Kissling Elke Leinisch Claudia Tiburtius Henning Clausen Bastian Cheng Stefan Blankenberg Max Nedelmann Andreas Steinbrecher Frank Andres Michael Rosenkranz Christoph Sinning Renate B. Schnabel Christian Gerloff Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T; M.U, M.J, J.S, E.B, B.C, C.G.). Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum, Hamburg, Germany (S.C, S.B, C.S, R.B.S.). DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C, M.J, S.B, C.S, R.B.S.). Klinik für Neurologie und Neurologische Frührehabilitation, Albertinen Krankenhaus, Hamburg, Germany (S.B, M.R.). Medizinische Klinik II, Kreiskliniken Reutlingen, Germany. (B.O.) Klinik für Neurologie, Kreiskliniken Reutlingen, Germany. (S.K, F.A.) Klinik für Neurologie, Helios Klinikum Erfurt, Germany (E.L, A.S.). Klinik für Kardiologie, Albertinen Krankenhaus, Hamburg, Germany (C.T.). Klinik für Neurologie, Regio Kliniken Pinneberg, Germany (H.C, M.N.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Cardiac ultrasound to identify sources of cardioembolism is part of the diagnostic workup of acute ischemic stroke. Recommendations on whether transesophageal echocardiography (TEE) should be performed in addition to transthoracic echocardiography (TTE) are controversial. We aimed to determine the incremental diagnostic yield of TEE in addition to TTE in patients with acute ischemic stroke with undetermined cause.Methods:In a prospective, observational, pragmatic multicenter cohort study, patients with acute ischemic stroke or transient ischemic attack with undetermined cause before cardiac ultrasound were studied by TTE and TEE. The primary outcome was the rate of treatment-relevant findings in TTE and TEE as defined by a panel of experts based on current evidence. Further outcomes included the rate of changes in the assessment of stroke cause after TEE.Results:Between July 1, 2017, and June 30, 2019, we enrolled 494 patients, of whom 492 (99.6%) received TTE and 454 (91.9%) received TEE. Mean age was 64.7 years, and 204 (41.3%) were women. TEE showed a higher rate of treatment-relevant findings than TTE (86 [18.9%] versus 64 [14.1%],P<0.001). TEE in addition to TTE resulted in 29 (6.4%) additional patients with treatment-relevant findings. Among 191 patients ≤60 years additional treatment-relevant findings by TEE were observed in 27 (14.1%) patients. Classification of stroke cause changed after TEE in 52 of 453 patients (11.5%), resulting in a significant difference in the distribution of stroke cause before and after TEE (P<0.001).Conclusions:In patients with undetermined cause of stroke, TEE yielded a higher number of treatment-relevant findings than TTE. TEE appears especially useful in younger patients with stroke, with treatment-relevant findings in one out of seven patients ≤60 years.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT03411642.
      Citation: Stroke
      PubDate: 2021-09-09T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034868
       
  • StrokeCog Markov Model: Projected Prevalent and Incident Cases of Stroke
           and Poststroke Cognitive Impairment to 2035 in Ireland

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      Authors: Eithne Sexton Nora-Ann Donnelly Niamh A. Merriman Anne Hickey Maev-Ann Wren Martin O’Flaherty Piotr Bandosz Maria Guzman-Castillo David J. Williams Frances Horgan Niall Pender Joanne Feeney Céline de Looze Rose Anne Kenny Peter Kelly Kathleen Bennett Division of Population Health Sciences; RCSI University of Medicine Health Sciences, Dublin, Ireland (F.H.). Department of Psychology, Beaumont Hospital, Dublin, Ireland (N.P.). The Irish Longitudinal Study on Ageing, School of Medicine, Trinity College Dublin, Ireland (J.F., C.d.L., R.A.K.). Department of Medical Gerontology, St James Hospital, Dublin, Ireland (R.A.K.). Mater University Hospital/University College Dublin, Ireland (P.K.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Cognitive impairment no dementia (CIND) and dementia are common stroke outcomes, with significant health and societal implications for aging populations. These outcomes are not included in current epidemiological models. We aimed to develop an epidemiological model to project incidence and prevalence of stroke, poststroke CIND and dementia, and life expectancy, in Ireland to 2035, informing policy and service planning.Methods:We developed a probabilistic Markov model (the StrokeCog model) applied to the Irish population aged 40 to 89 years to 2035. Data sources included official population and hospital-episode statistics, longitudinal cohort studies, and published estimates. Key assumptions were varied in sensitivity analysis. Results were externally validated against independent sources. The model tracks poststroke progression into health states characterized by no cognitive impairment, CIND, dementia, disability, stroke recurrence, and death.Results:We projected 69 051 people with prevalent stroke in Ireland in 2035 (22.0 per 1000 population [95% CI, 20.8–23.1]), with 25 274 (8.0 per 1000 population [95% CI, 7.1–9.0]) of those projected to have poststroke CIND, and 12 442 having poststroke dementia (4.0 per 1000 population [95% CI, 3.2–4.8]). We projected 8725 annual incident strokes in 2035 (2.8 per 1000 population [95% CI, 2.7–2.9]), with 3832 of these having CIND (1.2 per 1000 population [95% CI, 1.1–1.3]), and 1715 with dementia (0.5 per 1000 population [95% CI, 0.5–0.6]). Life expectancy for stroke survivors at age 50 was 23.4 years (95% CI, 22.3–24.5) for women and 20.7 (95% CI, 19.5–21.9) for men.Conclusions:This novel epidemiological model of stroke, poststroke CIND, and dementia draws on the best available evidence. Sensitivity analysis indicated that findings were robust to assumptions, and where there was uncertainty a conservative approach was taken. The StrokeCog model is a useful tool for service planning and cost-effectiveness analysis and is available for adaptation to other national contexts.
      Citation: Stroke
      PubDate: 2021-09-09T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034005
       
  • Thrombolysis in Mild Stroke: A Comparative Analysis of the PRISMS and
           MaRISS Studies

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      Authors: Negar Asdaghi Jose G. Romano Hannah Gardener Iszet Campo-Bustillo Barbara Purdon Yosef M. Khan Deepak Gulati Joseph P. Broderick Lee H. Schwamm Eric E. Smith Jeffrey L. Saver Ralph Sacco Pooja Khatri Department of Neurology; University of Miami Miller School of Medicine, FL (N.A., J.G.R., H.G., I.C.-B., R.S.). Genentech, South San Francisco, CA (B.P.). The American Heart Association, Dallas, TX (Y.M.K.). Neurology Department, The Ohio State University College of Medicine, Columbus (D.G., J.P.B.). Department of Neurology Investigators Opeolu Adeoye Elisheva Coleman Stacie Demel Bryan Eckerle Matthew Flaherty Anna Gensic Sabreena Gillow Adam Jasne Daniel Kanter Rahul Karamchandani Brian Katz Brett Kissela Dawn Kleindorfer Natalie Kreitzer Julian Macedo Erin McDonough Brian Oloizia Arthur Pancioli Blake Smith Michael Star Brian Stettler Kyle Walsh Daniel Woo Thomas Devlin Robert Sawyer Maxim Hammer Ashutosh Jadhav Tudor Jovin Cynthia Kenmuir Marcelo Rocha Matthew Starr Lawrence Wechsler Brian Katz Jennifer Mejilla Pramodkumar Sethi Rebecca Sugg Amelia Adcock Muhammad Alvi John Brick Matthew Smith Paul Katz Jorge Ivan Lopez Shyam Prabhakaran Valerie Dechant Jason Nomura Jonathan Raser- Schramm Bradley Jacobs Gerald McIntosh Stanley Tuhrim Gerald Ferencz John Sarris Ameer Hassan Edward Luke Bradbury Jana Wold John Cochran Vipan Gupta Moayd Alkhalifah Varun Chaubal George Dillon Andrea Escobar Paul Gadient Sebastian Koch Avi Landman Amer Malik Erika Marulanda-Londono Gustavo Ortiz Pankaj Sharma Clinton Wright Wei Liu Kerri Remmel Jignesh Shah Elizabeth Wise Souvic Sen Johnson Moon Fen-Lei Chang Judd Jensen James Gebel Christine Holmstedt Kunal Agrawal Maysun Ali Ronelyn Chavez Robert Claycomb Lovella Hailey Thomas Hemmen James Ho Branko Huisa Brett Meyer Dawn Meyer Royya Modir Melissa Mortin Rajiv Narula David Nguyen Mohsen Pirastehfar Hami Ramani Karen Rapp Kathleen Rickes Kristin Woods Aaron Stayman Joshua Willey Adrian Goldszmidt Ken Uchino Allison Arch Arun Chhabra Lindsey Frischmann Jason Hinman Mersedeh Bahr Hosseini David Liebeskind Konark Malhotra Neal Rao Latisha Sharma Sidney Starkman Xander Tang Anita Tipirneni Parampreet Walia David Chiu Mohammed Ibrahim Susanth Aroor Sourabh Lahoti Jessica Lee Danny Rose Francisco Esparza Nada Abou Fayssal Michael Lyerly Jon Schrock Shlee Song Yongwoo Kim Steven Levine Adrian Marchidann Diana Rojas-Soto Jerome Salvani Artem Sunik Douglas Franz Sarah Song Mahmoud Abu-Ata Mohammed Alhatou Robert Felberg Mouhammed Kubbani Michael Leone Ragasri Kumar Andria Ford Laura Heitsch Jin-Moo Lee Brandi French Syed Zaidi
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Mild ischemic stroke patients enrolled in randomized controlled trials of thrombolysis may have a different symptom severity distribution than those treated in routine clinical practice.Methods:We compared the distribution of the National Institutes of Health Stroke Scale (NIHSS) scores, neurological symptoms/severity among patients enrolled in the PRISMS (Potential of r-tPA for Ischemic Strokes With Mild Symptoms) randomized controlled trial to those with NIHSS score ≤5 enrolled in the prospective MaRISS (Mild and Rapidly Improving Stroke Study) registry using globalPvalues from χ2analyses.Results:Among 1736 participants in MaRISS, 972 (56%) were treated with alteplase and 764 (44%) were not. These participants were compared with 313 patients randomized in PRISMS. The median NIHSS scores were 3 (2–4) in MaRISS alteplase-treated, 1 (1–3) in MaRISS non–alteplase-treated, and 2 (1–3) in PRISMS. The percentage with an NIHSS score of 0 to 2 was 36.3%, 73.3%, and 65.2% in the 3 groups, respectively (P<0.0001). The proportion of patients with a dominant neurological syndrome (≥1 NIHSS item score of ≥2) was higher in MaRISS alteplase-treated (32%) compared with MaRISS nonalteplase-treated (13.8%) and PRISMS (8.6%;P<0.0001).Conclusions:Patients randomized in PRISMS had comparable deficit and syndromic severity to patients not treated with alteplase in the MaRISS registry and lesser severity than patients treated with alteplase in MaRISS. The PRISMS trial cohort is representative of mild patients who do not receive alteplase in current broad clinical practice.
      Citation: Stroke
      PubDate: 2021-09-09T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033466
       
  • Comparing Warfarin and 4 Direct Oral Anticoagulants for the Risk of
           Dementia in Patients With Atrial Fibrillation

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      Authors: So-Ryoung Lee Eue-Keun Choi Sang-Hyun Park Jin-Hyung Jung Kyung-Do Han Seil Oh Gregory Y.H. Lip Department of Internal Medicine; Seoul National University Hospital, Republic of Korea (S.-R.L., E.-K.C., S.O.). Department of Internal Medicine, Seoul National University College of Medicine, Republic of Korea (E.-K.C., S.O., G.Y.H.L.). Department of Medical Statistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea (E.-K.C., S.O., G.Y.H.L.). Statistics Chest Hospital, United Kingdom (K.-D.H., G.Y.H.L.). Department of Clinical Medicine, Aalborg University, Denmark (G.Y.H.L.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Atrial fibrillation is a risk factor for dementia, and oral anticoagulant use is associated with a decreased risk of dementia in patients with atrial fibrillation. We aimed to investigate whether the risk of dementia would be different between patients treated with direct oral anticoagulants (DOACs) compared with those with warfarin.Methods:Using the Korean nationwide claims database from January 2014 to December 2017, we identified oral anticoagulant–naive nonvalvular atrial fibrillation patients aged ≥40 years. For the comparisons, warfarin and DOAC groups were balanced using the inverse probability of treatment weighting method. The primary outcome was incident dementia.Results:Among 72 846 of total study patients, 25 948 were treated with warfarin, and 46 898 were treated with DOAC (17 193 with rivaroxaban, 9882 with dabigatran, 11 992 with apixaban, and 7831 with edoxaban). During mean 1.3±1.1 years of follow-up, crude incidence of dementia was 4.87 per 100 person-years (1.20 per 100 person-years for vascular dementia and 3.30 per 100 person-years for Alzheimer dementia). Compared with warfarin, DOAC showed a comparable risks of dementia, vascular dementia, and Alzheimer dementia. In subgroup analyses, DOAC was associated with a lower risk of dementia than warfarin, particularly in patients aged 65 to 74 years (hazard ratio, 0.815 [95% CI, 0.709–0.936]) and in patients with prior stroke (hazard ratio, 0.891 [95% CI, 0.820–0.968]). When comparing individual DOACs with warfarin, edoxaban was associated with a lower risk of dementia (hazard ratio, 0.830 [95% CI, 0.740–0.931]).Conclusions:In this large Asian population with atrial fibrillation, DOAC showed a comparable risk of dementia with warfarin overall. DOACs appeared more beneficial than warfarin, in those aged 65 to 74 years or with a history of stroke. For specific DOACs, only edoxaban was associated with a lower risk of dementia than warfarin.
      Citation: Stroke
      PubDate: 2021-09-09T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033338
       
  • Deep Learning–Based Automated Thrombolysis in Cerebral Infarction
           Scoring: A Timely Proof-of-Principle Study

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      Authors: Maximilian Nielsen Moritz Waldmann Andreas M. Frölich Fabian Flottmann Evelin Hristova Martin Bendszus Fatih Seker Jens Fiehler Thilo Sentker Rene Werner Department of Computational Neuroscience; University Medical Center-Hamburg-Eppendorf, Germany. (M.N., T.S., R.W.) Center for Biomedical Artificial Intelligence (bAIome), University Medical Center-Hamburg-Eppendorf, Germany. (M.N., T.S., R.W.) Department of Diagnostic Interventional Neuroradiology, University Medical Center-Hamburg-Eppendorf, Germany. (M.W., A.M.F., F.F., J.F.) Eppdata GmbH, Hamburg, Germany (E.H.). Department of Neuroradiology, Heidelberg University Hospital, Germany (M.B., F.S.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Mechanical thrombectomy is an established procedure for treatment of acute ischemic stroke. Mechanical thrombectomy success is commonly assessed by the Thrombolysis in Cerebral Infarction (TICI) score, assigned by visual inspection of X-ray digital subtraction angiography data. However, expert-based TICI scoring is highly observer-dependent. This represents a major obstacle for mechanical thrombectomy outcome comparison in, for instance, multicentric clinical studies. Focusing on occlusions of the M1 segment of the middle cerebral artery, the present study aimed to develop a deep learning (DL) solution to automated and, therefore, objective TICI scoring, to evaluate the agreement of DL- and expert-based scoring, and to compare corresponding numbers to published scoring variability of clinical experts.Methods:The study comprises 2 independent datasets. For DL system training and initial evaluation, an in-house dataset of 491 digital subtraction angiography series and modified TICI scores of 236 patients with M1 occlusions was collected. To test the model generalization capability, an independent external dataset with 95 digital subtraction angiography series was analyzed. Characteristics of the DL system were modeling TICI scoring as ordinal regression, explicit consideration of the temporal image information, integration of physiological knowledge, and modeling of inherent TICI scoring uncertainties.Results:For the in-house dataset, the DL system yields Cohen’s kappa, overall accuracy, and specific agreement values of 0.61, 71%, and 63% to 84%, respectively, compared with the gold standard: the expert rating. Values slightly drop to 0.52/64%/43% to 87% when the model is, without changes, applied to the external dataset. After model updating, they increase to 0.65/74%/60% to 90%. Literature Cohen’s kappa values for expert-based TICI scoring agreement are in the order of 0.6.Conclusions:The agreement of DL- and expert-based modified TICI scores in the range of published interobserver variability of clinical experts highlights the potential of the proposed DL solution to automated TICI scoring.
      Citation: Stroke
      PubDate: 2021-09-09T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033807
       
  • Long-Term Survival, Causes of Death, and Trends in 5-Year Mortality After
           Intracerebral Hemorrhage: The Tromsø Study

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      Authors: Maria Carlsson Tom Wilsgaard Stein Harald Johnsen Liv-Hege Johnsen Maja-Lisa Løchen Inger Njølstad Ellisiv B. Mathiesen Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø. (M.C; S.H.J, L.-H.J, E.B.M.) Department of Community Medicine, UiT The Arctic University of Norway, Tromsø. (T.W, M.-L.L, I.N.) Department of Neurology, Nordland Hospital Trust, Bodø, Norway (M.C.). Department of Neurology, University Hospital of North Norway, Tromsø. (S.H.J, E.B.M.) Department of Radiology, University Hospital of North Norway, Tromsø. (L.-H.J.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Data on long-term survival after intracerebral hemorrhage (ICH) are scarce. In a population-based nested case-control study, we compared long-term survival and causes of death within 5 years in 30-day survivors of first-ever ICH and controls, assessed the impact of cardiovascular risk factors on 5-year mortality, and analyzed time trend in 5-year mortality in ICH patients over 2 decades.Methods:We included 219 participants from the population-based Tromsø Study, who after the baseline participation had a first-ever ICH between 1994 to 2013 and 1095 age- and sex-matched participants without ICH. Cumulative survival was presented using the Kaplan-Meier method. Hazard ratios (HRs) for mortality and for the association between cardiovascular risk factors and 5-year mortality in 30-day survivors were estimated by stratified Cox proportional hazards models. Trend in 5-year mortality was assessed by logistic regression.Results:Risk of death during follow-up (median time, 4.8 years) was increased in the ICH group compared with controls (HR, 1.62 [95% CI, 1.27–2.06]). Cardiovascular disease was the leading cause of death, with a higher proportion in ICH patients (22.9% versus 9.0%;P<0.001). Smoking increased the risk of 5-year mortality in cases and controls (HR, 1.59 [95% CI, 1.15–2.19]), whereas serum cholesterol was associated with 5-year mortality in cases only (HR, 1.39 [95% CI, 1.04–1.86]). Use of anticoagulants at ICH onset increased the risk of death (HR, 2.09 [95% CI, 1.09–4.00]). There was no difference according to ICH location (HR, 1.15 [95% CI, 0.56–2.37]). Five-year mortality did not change during the study period (odds ratio per calendar year, 1.01 [95% CI, 0.93–1.09]).Conclusions:Survival rates were significantly lower in cases than in controls, driven by a 2-fold increased risk of cardiovascular death. Smoking, serum cholesterol, and use of anticoagulant drugs were associated with increased risk of death in ICH patients. Five-year mortality rates in ICH patients remained stable over time.
      Citation: Stroke
      PubDate: 2021-09-09T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.032750
       
  • Peanut Consumption and Risk of Stroke and Ischemic Heart Disease in
           Japanese Men and Women: The JPHC Study

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      Authors: Satoyo Ikehara Hiroyasu Iso Yoshihiro Kokubo Kazumasa Yamagishi Isao Saito Hiroshi Yatsuya Takashi Kimura Norie Sawada Motoki Iwasaki Shoichiro Tsugane Public Health; Department of Social Medicine, Osaka University Graduate School of Medicine, Suita, Japan (S.I., H.I.). Department of Public Health Medicine, Faculty of Medicine, Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan (N.S., M.I., S.T.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Several prospective cohort studies and a randomized clinical trial have shown the beneficial effects of peanut consumption on cardiovascular disease and its risk factors. We examined the association between peanut consumption and risk of cardiovascular disease in Japanese men and women.Methods:We analyzed data of 74 793 participants aged 45 to 74 years who completed a lifestyle questionnaire including the validated food frequency questionnaire in the Japan Public Health Center–based Prospective Study. They were followed up from 1995 to 2009 for cohort I and from 1998 to 1999 to 2012 for cohort II. Peanut consumption was calculated from the food frequency questionnaire, and the end points were incidence of stroke, ischemic heart disease, and cardiovascular disease (stroke and ischemic heart disease).Results:During a median follow-up of 14.8 years, 3,599 strokes and 849 ischemic heart diseases were reported. Higher peanut consumption was associated with reduced risks of total stroke, ischemic stroke, and cardiovascular disease among men and women. The multivariable hazard ratios (95% CIs) for the highest versus lowest quartiles of peanut consumption after adjustment for age, sex, public health center, smoking, alcohol consumption, perceived stress level, physical activity, vegetable, fruit, fish, soy, sodium and total energy intakes, body mass index, history of hypertension, history of diabetes, and cholesterol-lowering drug were 0.84 (0.77–0.93,Pfor trend=0.002) for total stroke, 0.80 (0.71–0.90,Pfor trend=0.002) for ischemic stroke, 0.93 (0.79–1.08,Pfor trend=0.27) for hemorrhagic stroke, 0.97 (0.80–1.17,Pfor trend=0.81) for ischemic heart disease and 0.87 (0.80–0.94,Pfor trend=0.004) for cardiovascular disease, and these associations were similarly observed in both sexes.Conclusions:Higher peanut consumption was associated with reduced risk of stroke, especially ischemic stroke, but not ischemic heart disease in Japanese men and women.
      Citation: Stroke
      PubDate: 2021-09-09T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.031212
       
  • Factors Associated With Decreased Accuracy of Modified Thrombolysis in
           Cerebral Infarct Scoring Among Neurointerventionalists During Thrombectomy
           

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      Authors: Elliot Pressman Muhammad Waqas Victoria Sands Adnan Siddiqui Kenneth Snyder Jason Davies Elad Levy Ciprian Ionita Waldo Guerrero Zeguang Ren Maxim Mokin Department of Neurosurgery, University of South Florida, Tampa (E.P; V.S, W.G, Z.R, M.M.). Department of Neurosurgery, University at Buffalo, NY (M.W, A.S, K.S, J.D, E.L, C.I.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The modified thrombolysis in cerebral infarct (mTICI) score is used to grade angiographic outcome after endovascular thrombectomy. We sought to identify factors that decrease the accuracy of intraprocedural mTICI.Methods:We performed a 2-center retrospective cohort study comparing operator (n=6) mTICI scores to consensus scores from blinded adjudicators. Groups were also assessed by dichotomizing mTICI scores to 0–2a versus 2b–3.Results:One hundred thirty endovascular thrombectomy procedures were included. Operators and adjudicators had a pairwise agreement in 96 cases (73.8%). Krippendorff α was 0.712. Multivariate analysis showed endovascular thrombectomy overnight (odds ratio [OR]=3.84 [95% CI, 1.22–12.1]), lacking frontal (OR, 5.66 [95 CI, 1.36–23.6]), or occipital (OR, 7.18 [95 CI, 2.12–24.3]) region reperfusion, and higher operator mTICI scores (OR, 2.16 [95 CI, 1.16–4.01]) were predictive of incorrectly scoring mTICI intraprocedurally. With dichotomized mTICI scores, increasing number of passes was associated with increased risk of operator error (OR, 1.93 [95 CI, 1.22–3.05]).Conclusions:In our study, mTICI disagreement between operator and adjudicators was observed in 26.2% of cases. Interventions that took place between 22:30 and 4:00, featured frontal or occipital region nonperfusion, higher operator mTICI scores, and increased number of passes had higher odds of intraprocedural mTICI inaccuracy.
      Citation: Stroke
      PubDate: 2021-09-09T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033372
       
  • Making the Right Call: Human Biases and Still Learning Machines

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      Authors: Yasmin N. Aziz Joseph P. Broderick University of Cincinnati Gardner Neuroscience Institute; University of Cincinnati, OH.
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-09-09T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.036758
       
  • Direct Oral Anticoagulants and Prevention of Dementia in Nonvalvular
           Atrial Fibrillation

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      Authors: Sarah T. Pendlebury Wolfson Centre for Prevention of Stroke; Geratology, Oxford University Hospitals NHS Foundation Trust, United Kingdom.
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-09-09T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.035664
       
  • Eating Well to Prevent Stroke: Peanuts Are on the Plate

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      Authors: Walter N. Kernan Department of Medicine; Yale School of Medicine, New Haven, CT.
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-09-09T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.036172
       
  • Ischemic Benefit and Hemorrhage Risk Of Ticagrelor-Aspirin Versus Aspirin
           In Patients With Acute Ischemic Stroke Or TIA

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      Authors: S. Claiborne Johnston Pierre Amarenco Maria Aunes Hans Denison Scott Evans Anders Himmelmann Marianne Jahreskog Stefan James Mikael Knutsson Per Ladenvall Carlos A. Molina Sven Nylander Joachim Röther Yongjun Wang Dean's Office; Dell Medical School, University of Texas, UNITED STATES Neurology Uppsala Clinical Research Center, Uppsala University, SWEDEN Biometrics, BioPharmaceuticals R&D, AstraZeneca, SWEDEN Biopharmaceuticals R&D, AstraZeneca, SWEDEN Neurology, Hospital Vall d'Hebron, SPAIN Translational Sciences, AstraZeneca R&D Sweden, SWEDEN Department of Neurology, Asklepios Klinik Altona Hamburg, GERMANY Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, CHINA
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:In patients with acute mild-moderate ischemic stroke or high-risk transient ischemic attack (TIA), the Acute Stroke or Transient Ischemic Attack Treated with Ticagrelor and Aspirin for Prevention of Stroke and Death (THALES) trial demonstrated that when added to aspirin, ticagrelor reduced stroke or death but increased risk of severe hemorrhage compared with placebo. The primary efficacy outcome of THALES included hemorrhagic stroke and death, events also counted in the primary safety outcome. We sought to disentangle risk and benefit, assess their relative impact, and attempt to identify subgroups with disproportionate risk or benefit.Methods:In a randomized, placebo-controlled, double-blind trial of patients with mild-to-moderate acute noncardioembolic ischemic stroke or high-risk TIA, patients were randomized within 24 hours after symptom onset to a 30-day regimen of either ticagrelor plus aspirin or matching placebo plus aspirin. For the present analyses, we defined the efficacy outcome, major ischemic events, as the composite of ischemic stroke or non-hemorrhagic death, and defined the safety outcome, major hemorrhage, as intracranial hemorrhage or hemorrhagic death. Net clinical impact was defined as the combination of these two endpoints.Results:In 11 016 patients (5523 ticagrelor-aspirin and 5493 aspirin), a major ischemic event occurred in 294 patients (5.3%) in the ticagrelor-aspirin group and in 359 patients (6.5%) in the aspirin group (absolute risk reduction 1.19%, 95%CI 0.31%-2.07%). Major hemorrhage occurred in 22 patients (0.4%) in the ticagrelor-aspirin group and 6 patients (0.1%) in the aspirin group (absolute risk increase 0.29%, 95% CI, 0.10-0.48%). Net clinical impact favored ticagrelor-aspirin (absolute risk reduction 0.97%, 95% CI, 0.08%-1.87%). Findings were similar when different thresholds for disability were applied and over a range of predefined subgroups.Conclusions:In patients with mild-moderate ischemic stroke or high-risk TIA, ischemic benefits of 30-day treatment with ticagrelor-aspirin outweigh risks of hemorrhage.Registration:URL: http://www.clinicaltrials.gov; Unique identifier: NCT03354429
      Citation: Stroke
      PubDate: 2021-09-03T03:10:28Z
      DOI: 10.1161/STROKEAHA.121.035555
       
  • Ultrasound-Guided BoNT-A (Botulinum Toxin A) Injection Into the
           Subscapularis for Hemiplegic Shoulder Pain: A Randomized, Double-Blind,
           Placebo-Controlled Trial

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      Authors: Botao Tan Lang Jia Department of Rehabilitation Medicine; Second Affiliated Hospital of Chongqing Medical University, China.
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:This study aimed to assess the efficacy of an ultrasound-guided lateral approach for BoNT-A (botulinum toxin A) injections into the subscapularis in patients with hemiplegic shoulder pain.Methods:This single-center trial used a randomized, double-blind, placebo-controlled design. The key inclusion criteria were a visual analog scale score of ≥4 cm and a modified Ashworth scale score of ≥1+. The patients were randomized to receive either BoNT-A injections or a placebo. The outcomes included the visual analog scale score, modified Ashworth scale score, pain-free passive range of motion of the hemiplegic shoulder, Fugl-Meyer assessment score for the upper extremities, and Stroke-Specific Quality-of-Life score.Results:A total of 49 hemiplegic shoulder pain patients were screened, and 36 were included. The participants receiving the BoNT-A injection reported a significant decrease in pain (visual analog scale, −1.39 [95% CI, −2.41 to −0.36];P=0.002) and spasticity (modified Ashworth scale score for shoulder internal rotation, −0.72 [95% CI, −1.10 to −0.35];P=0.001; modified Ashworth scale score for shoulder abduction, −0.44 [95% CI, −0.90 to −0.01];P=0.026) and improved pain-free passive shoulder internal rotation range of motion (14.56 [95% CI, 6.70–21.41];P<0.001) and quality of life (Stroke-Specific Quality-of-Life upper extremity subscale,P=0.025) compared with those receiving the placebo at the end point. The shoulder abduction range of motion did not significantly improve after the BoNT-A injection at the end point (P=0.127). In addition, the patients in the BoNT-A group showed significant improvements in the visual analog scale score and shoulder external rotation range of motion at the 12-week follow-up. No injection-related adverse events were observed during or after the interventions in either group.Conclusions:The ultrasound-guided lateral approach for BoNT-A injections into the subscapularis is a precise and reliable method for reducing pain and spasticity and improving quality of life in stroke survivors with hemiplegic shoulder pain.Registration:URL:https://www.chictr.org.cn; Unique identifier: ChiCTR1900023513.
      Citation: Stroke
      PubDate: 2021-09-02T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034049
       
  • Long-Term Evolution of Functional Limitations in Stroke Survivors Compared
           With Stroke-Free Controls: Findings From 15 Years of Follow-Up Across 3
           International Surveys of Aging

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      Authors: Andres Gil-Salcedo Aline Dugravot Aurore Fayosse Louis Jacob Mikaela Bloomberg Séverine Sabia Alexis Schnitzler Université de Paris; Inserm U1153, Epidemiology of Ageing Public Health, University College London, United Kingdom (M.B., S.S.). Université Versailles Saint Quentin en Yvelines, EA 4047 Handi-Resp, Garches, France (A.S.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:In the chronic phase 2 to 5 years poststroke, limitations in activities of daily living (ADL) and instrumental ADL (IADL) initially plateau before steady increasing. However, the impact of age and differences in initial levels of disability on the evolution of these limitations remains unclear. As such, this study aims to evaluate differences in long-term evolution of ADL/IADL limitations between stroke survivors and stroke-free population, and how limitations differ by initial level of disability for stroke survivors.Methods:Thirty-three thousand six hundred sixty participants (5610 first-ever stroke cases with no recurrence during follow-up and 28 050 stroke-free controls) aged ≥50 from the Health and Retirement Study, Survey of Health, Ageing and Retirement in Europe, and English Longitudinal Study of Ageing were assessed for number of ADL/IADL limitations during the poststroke chronic phase (for cases) and over follow-up years 1996 to 2018 (for controls). Three thousand seven hundred eighteen stroke cases were additionally categorized by disability level using the modified Rankin Scale score of 1 to 2 years poststroke. Evolution of ADL/IADL limitations was assessed in stroke cases and controls and by modified Rankin Scale score (0–1, 2–3, 4–5) using linear mixed models. Models were stratified by age group (50–74 and ≥75 years) and adjusted for baseline characteristics, health behaviors, BMI, and comorbidities.Results:Findings showed relative stability of ADL/IADL limitations during 3 to 6 years poststroke followed by an increase for both populations, which was faster for younger stroke cases, suggesting a differential age-effect (P<0.001). Disability level at 1 to 2 years poststroke influenced the evolution of limitations over time, especially for severe disability (modified Rankin Scale score, 4–5) associated with a reduction in limitations at 5 to 6 years poststroke.Conclusions:Our findings showed that during the poststroke chronic phase functional limitations first plateau and then increase and the evolution differs by disability severity. These results highlight the importance of adaptive long-term health and social care measures for stroke survivors.
      Citation: Stroke
      PubDate: 2021-09-02T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034534
       
  • Phase 1/2a Trial of ISPASM

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      Authors: Mario Zanaty Lauren Allan Edgar A. Samaniego Anthony Piscopo Eleanor Ryan James C. Torner David Hasan Department of Neurosurgery; University of Iowa Hospital Clinics. (J.C.T.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Microthrombosis could play a role in delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Tirofiban has shown promising results in reducing delayed cerebral ischemia in retrospective studies. However, the safety of using tirofiban in aneurysmal subarachnoid hemorrhage is not rigorously established.Methods:A phase 1/2a double-blinded randomized controlled trial (2:1 randomization) to assess the safety of a 7-day intravenous infusion of tirofiban compared with placebo, in patients with aneurysmal subarachnoid hemorrhage treated with ventriculostomy placed in the operative room and coiling was conducted. The primary end point was any intracranial hemorrhage during the hospital stay. The secondary end points were: incidence of radiographic and clinical vasospasm, incidence of delayed cerebral ischemia, and incidence of cerebral ischemic changes noted on magnetic resonance imaging or computed tomography.Results:Eighteen patients received intravenous tirofiban and 12 received placebo. There was no difference in baseline characteristics except for higher male proportions in the tirofiban group. There was no difference in death, in development of new or change in existing intracranial hemorrhages, in thrombocytopenia, and need for shunts in the two arms. However, the tirofiban arm had a lower incidence of delayed cerebral ischemia compared with placebo (6% [1/18] versus 33% [4/12];P=0.04), and less radiographic vasospasm as detected by catheter angiogram or computed tomography angiography (P=0.01) and computed tomography perfusion (P=0.01).Conclusions:The above preliminary results support proceeding with further testing of the safety and efficacy of 7-day intravenous infusion of tirofiban in a pragmatic (placing external ventricular drain by the bedside), multicenter setting, and using a larger population.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT03691727.
      Citation: Stroke
      PubDate: 2021-09-02T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034578
       
  • Atherogenic Dyslipidemia and Residual Vascular Risk After Stroke or
           Transient Ischemic Attack

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      Authors: Takao Hoshino Kentaro Ishizuka Sono Toi Takafumi Mizuno Ayako Nishimura Shuntaro Takahashi Sho Wako Kazuo Kitagawa Department of Neurology; Tokyo Women’s Medical University Hospital, Japan.
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Notwithstanding the current guideline-based management, patients with stroke retain a substantial risk of further vascular events. We aimed to assess the contribution of atherogenic dyslipidemia (AD) to this residual risk.Methods:This was a prospective observational study, in which 792 patients (mean age, 70.1 years; male, 60.2%) with acute ischemic stroke (n=710) or transient ischemic attack (n=82) within 1 week of onset were consecutively enrolled and followed for 1 year. AD was defined as having both elevated levels of triglycerides ≥150 mg/dL and low HDL-C (high-density lipoprotein cholesterol) <40 mg/dL in men or <50 mg/dL in women, under fasting conditions. The primary outcome was a composite of major adverse cardiovascular events, including nonfatal stroke, nonfatal acute coronary syndrome, and vascular death.Results:The prevalence of AD was 12.2%. Patients with AD more often had intracranial artery stenosis than those without (42.3% versus 24.1%;P=0.004), whereas no differences were observed in the prevalence of extracranial artery stenosis (17.7% versus 12.9%;P=0.62) or aortic plaques (33.3% versus 27.0%;P=0.87). At 1 year, patients with AD were at a greater risk of major adverse cardiovascular events (annual rate, 24.5% versus 10.6%; hazard ratio [95% CI], 2.33 [1.44–3.80]) and ischemic stroke (annual rate, 16.8% versus 8.6%; hazard ratio [95% CI], 1.84 [1.04–3.26]) than those without AD. When patients were stratified according to baseline LDL-C (low-density lipoprotein cholesterol) level, AD was predictive of major adverse cardiovascular events among those with LDL-C ≥100 mg/dL (n=509; annual rate, 20.5% versus 9.6%;P=0.036) as well as those with LDL-C <100 mg/dL (n=283; annual rate, 38.6% versus 12.4%;P<0.001).Conclusions:AD is associated with intracranial artery atherosclerosis and a high residual vascular risk after a stroke or transient ischemic attack. AD should be a promising modifiable target for secondary stroke prevention.REGISTRATION:URL:https://upload.umin.ac.jp; Unique identifier: UMIN000031913.
      Citation: Stroke
      PubDate: 2021-09-02T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034593
       
  • Frequency, Characteristics, and Outcomes of Endovascular Thrombectomy in
           Patients With Stroke Beyond 6 Hours of Onset in US Clinical Practice

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      Authors: Kori S. Zachrison Lee H. Schwamm Haolin Xu Roland Matsouaka Shreyansh Shah Eric E. Smith Ying Xian Gregg C. Fonarow Jeffrey Saver Department of Emergency Medicine, Massachusetts General Hospital, Boston. (K.S.Z) Department of Neurology, Massachusetts General Hospital, Boston. (L.H.S.) Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (H.X; R.M.) Department of Neurology, Duke University School of Medicine, Durham, NC. (S.S.) Department of Medicine, Duke University School of Medicine, Durham, NC. (Y.X.) Department of Neurology, University of Calgary, AB (E.E.S.). Division of Cardiology, University of California Los Angeles (G.C.F.) Department of Neurology, University of California Los Angeles (J.S.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:In 2018, 2 randomized controlled trials showed the benefit of endovascular thrombectomy (EVT) in acute ischemic stroke patients treated 6 to 24 hours from last known well using imaging-guided selection. However, little is known about outcomes in contemporary nontrial settings. We assessed the frequency of EVT and outcomes beyond 6 hours in the US Get With The Guidelines–Stroke clinical registry.Methods:We analyzed all acute ischemic stroke patients treated with EVT between January 1, 2009 and October, 1, 2018, at Get With The Guidelines–Stroke hospitals in the United States. We assessed trends over time in frequency of EVT beyond 6 hours, compared patient characteristics and outcomes between those treated within versus beyond 6 hours, and evaluated the associations between EVT time and outcomes.Results:We identified 53 702 patients at 697 sites treated with EVT during the study period. Treatment after 6 hours from last known well occurred in 17 720 (33%) of all 53 702 EVT cases (median 4.7 hours, interquartile range, 3.3–7 hours). The proportion of EVT cases treated after 6 hours from last known well varied widely across sites (median 30%, interquartile range, 24%–38%). Compared with patients treated within 6 hours, those treated beyond six hours were younger, less likely to have atrial fibrillation, less likely to arrive by ambulance, had lower stroke severity, were less likely to be anticoagulated, and more likely to be treated at centers with higher EVT volumes. After adjusting for patient and hospital characteristics, patients receiving EVT beyond 6 hours had less favorable in-hospital mortality, ambulation at discharge, and discharge disposition compared to those treated within 6 hours.Conclusions:EVT is frequently performed for patients with ischemic stroke after 6 hours from last known well, accounting for one-third of cases nationally, and adjusted functional outcomes at discharge are worse in these patients compared to those treated with EVT within 6 hours. Further efforts are needed for optimal EVT outcomes in clinical practice settings.
      Citation: Stroke
      PubDate: 2021-09-02T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034069
       
  • Pediatric Ischemic Stroke and Epilepsy: A Nationwide Cohort Study

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      Authors: Heléne E.K. Sundelin Torbjörn Tomson Johan Zelano Jonas Söderling Peter Bang Jonas F. Ludvigsson Division of Children’s; Public Health, School of Medicine, University of Nottingham, United Kingdom (J.F.L.). Department of Medicine, Columbia University, NY (J.F.L.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The risk of epilepsy after stroke has not been thoroughly explored in pediatric ischemic stroke. We examined the risk of epilepsy in children with ischemic stroke as well as in their first-degree relatives.Methods:In Swedish National Registers, we identified 1220 children <18 years with pediatric ischemic stroke diagnosed 1969 to 2016, alive 7 days after stroke and with no prior epilepsy. We used 12 155 age- and sex-matched individuals as comparators. All first-degree relatives to index individuals and comparators were also identified. The risk of epilepsy was estimated in children with ischemic stroke and in their first-degree relatives using Cox proportional hazard regression model.Results:Through this nationwide population-based study, 219 (18.0%) children with ischemic stroke and 91 (0.7%) comparators were diagnosed with epilepsy during follow-up corresponding to a 27.8-fold increased risk of future epilepsy (95% CI, 21.5–36.0). The risk of epilepsy was still elevated after 20 years (hazard ratio [HR], 7.9 [95% CI, 3.3–19.0]), although the highest HR was seen in the first 6 months (HR, 119.4 [95% CI, 48.0–297.4]). The overall incidence rate of epilepsy was 27.0 per 100 000 person-years (95% CI, 21.1–32.8) after ischemic stroke diagnosed ≤day 28 after birth (perinatal) and 11.6 per 100 000 person-years (95% CI, 9.6–13.5) after ischemic stroke diagnosed ≥day 29 after birth (childhood). Siblings and parents, but not offspring, to children with ischemic stroke were at increased risk of epilepsy (siblings: HR, 1.64 [95% CI, 1.08–2.48] and parents: HR, 1.41 [95% CI, 1.01–1.98]).Conclusions:The risk of epilepsy after ischemic stroke in children is increased, especially after perinatal ischemic stroke. The risk of epilepsy was highest during the first 6 months but remained elevated even 20 years after stroke which should be taken into account in future planning for children affected by stroke.
      Citation: Stroke
      PubDate: 2021-09-02T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034796
       
  • Racial Differences in Blood Pressure Control Following Stroke: The REGARDS
           Study

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      Authors: Oluwasegun P. Akinyelure Byron C. Jaeger Tony L. Moore Demetria Hubbard Suzanne Oparil Virginia J. Howard George Howard Joy N. Buie Gayenell S. Magwood Robert J. Adams Leonardo Bonilha Daniel T. Lackland Paul Muntner Department of Epidemiology, School of Public Health, University of Alabama at Birmingham. (O.P.A; T.L.M, D.H, V.J.H, P.M.) Department of Biostatistics, School of Public Health, University of Alabama at Birmingham. (B.C.J, G.H.) Department of Medicine, University of Alabama at Birmingham. (S.O.) Department of Neurology, Medical University of South Carolina, Charleston. (J.N.B, R.J.A, L.B, D.T.L.) Department of Nursing, Medical University of South Carolina, Charleston. (G.S.M.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:In the general population, Black adults are less likely than White adults to have controlled blood pressure (BP), and when not controlled, they are at greater risk for stroke compared with White adults. High BP is a major modifiable risk factor for recurrent stroke, but few studies have examined racial differences in BP control among stroke survivors.Methods:We used data from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) to examine disparities in BP control between Black and White adults, with and without a history of stroke. We studied participants taking antihypertensive medication who did and did not experience an adjudicated stroke (n=306 and 7693 participants, respectively) between baseline (2003–2007) and a second study visit (2013–2016). BP control at the second study visit was defined as systolic BP <130 mm Hg and diastolic BP <80 mm Hg except for low-risk adults ≥65 years of age (ie, those without diabetes, chronic kidney disease, history of cardiovascular disease, and with a 10-year predicted atherosclerotic cardiovascular disease risk <10%) for whom BP control was defined as systolic BP <130 mm Hg.Results:Among participants with a history of stroke, 50.3% of White compared with 39.3% of Black participants had controlled BP. Among participants without a history of stroke, 56.0% of White compared with 50.2% of Black participants had controlled BP. After multivariable adjustment, there was a tendency for Black participants to be less likely than White participants to have controlled BP (prevalence ratio, 0.77 [95% CI, 0.59–1.02] for those with a history of stroke and 0.92 [95% CI, 0.88–0.97] for those without a history of stroke).Conclusions:There was a lower proportion of controlled BP among Black compared with White adults with or without stroke, with no statistically significant differences after multivariable adjustment.
      Citation: Stroke
      PubDate: 2021-09-02T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033108
       
  • Outcomes Among Patients With Reversible Cerebral Vasoconstriction
           Syndrome: A Nationwide United States Analysis

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      Authors: Smit D. Patel Karan Topiwala Fadar Otite Oliver Hamidreza Saber Gregory Panza Gracia Mui David S. Liebeskind Jeffrey L. Saver Mark Alberts Anne Ducros Neurology Department, University of Connecticut/Hartford Hospital (S.D.P; G.M, M.A.). Neurology Department, University of Minnesota, Minneapolis (K.T.). Neurology Department, State University of New York (SUNY) Upstate Medical University, Syracuse, NY (F.O.O.). Neurology Department, University of California of Los Angelos (H.S, D.S.L, J.L.S.). Department of Research, Hartford Hospital, CT (G.P.). Neurology Department, Montpellier University Hospital, France (A.D.). Laboratory Charles Coulomb UMR 5221 CNRS-UM, Montpellier University, France (A.D.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Reversible cerebral vasoconstriction syndrome (RCVS) is a well-established cause of stroke, but its demographics and outcomes have not been well delineated.Methods:Analysis of the United States Nationwide Inpatient Sample database (2016–2017) to characterize the frequency of hospitalizations for RCVS, demographic features, inpatient mortality, and discharge outcomes.Results:During the 2-year study period, 2020 patients with RCVS were admitted to Nationwide Inpatient Sample hospitals, representing 0.02 cases per 100 000 national hospitalizations. The mean age at admission was 47.6 years, with 85% under 65 years of age, and 75.5% women. Concomitant neurological diagnoses during hospitalization included ischemic stroke (17.1%), intracerebral hemorrhage (11.0%), subarachnoid hemorrhage (32.7%), seizure disorders (6.7%), and reversible brain edema (13.6%). Overall, 70% of patients were discharged home, 29.7% discharged to a rehabilitation facility or nursing home and 0.3% died before discharge. Patient features independently associated with the poor outcome of discharge to another facility or death were advanced age (odds ratio [OR], 1.04 [95% CI, 1.03–1.04]), being a woman (OR, 2.45 [1.82–3.34]), intracerebral hemorrhage (OR, 2.91 [1.96–4.31]), ischemic stroke (OR, 5.72 [4.32–7.58]), seizure disorders (OR, 2.61 [1.70–4.00]), reversible brain edema (OR, 6.26 [4.41–8.89]), atrial fibrillation (OR, 2.97 [1.83–4.81]), and chronic kidney disease (OR, 3.43 [2.19–5.36]).Conclusions:Projected to the entire US population, >1000 patients with RCVS are hospitalized each year, with the majority being middle-aged women, and about 300 required at least some rehabilitation or nursing home care after discharge. RCVS-related inpatient mortality is rare.
      Citation: Stroke
      PubDate: 2021-09-02T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034424
       
  • Incidence, Risk Factors, and Outcomes of Stroke Following Cardiac
           Transplantation

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      Authors: Hilmi Alnsasra Rabea Asleh Neeraj Kumar Camden Lopez Takumi Toya Walter K. Kremers Brooks Edwards Richard C. Daly Sudhir S. Kushwaha Department of cardiovascular diseases, Mayo Clinic, Rochester, MN. (H.A; R.A, C.L, T.T, W.K.K, B.E, R.C.D, S.S.K.) Department of Neurology, Mayo Clinic, Rochester, MN. (N.K.) Soroka University Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel (H.A.). Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel (R.A.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Less is known about the risk factors and outcomes associated with stroke in the current era of increasing heart transplantation (HT) being performed in older patients. The impact of immunosuppression on risk of stroke has not yet been previously studied. We aimed to determine the incidence, risk factors and outcomes of stroke after HT.Methods:We retrospectively analyzed the incidence of ischemic and hemorrhagic strokes and associated outcomes in all consecutive HT recipients transplanted between 1994 and 2016 at a single institution.Results:Of 529 patients who underwent HT, 57 (10.7%) developed stroke, 8.1% had an ischemic events and (2.6%) had a hemorrhagic stroke. Age at HT (adjusted hazard ratio [HR] 1.33;P=0.03) and diabetes (HR, 2.60;P=0.02) were associated with increased risk of ischemic events. Patients with stroke (any type) were more likely to have worse kidney function (HR, 1.81;P=0.02) whereas patients with ischemic events were more likely to undergo combined organ transplantation (HR, 2.01;P=0.05). Cytomegalovirus infection was found to be associated with increased risk of any stroke (HR, 2.09;P=0.02).Conversion from calcineurin inhibitor to sirolimus-based immunosuppression was not found to be associated with a significant change in stroke risk (HR, 1.39;P=0. 45) compared with calcineurin inhibitor maintenance therapy. Stroke of any type and ischemic events were independently associated with increased risk of death (HR, 1.90;P=0.001 and HR, 2.14;P<0.001, respectively).Conclusions:Stroke after HT is associated with increased mortality. Older age at HT, diabetes, renal dysfunction, and CMV infection were associated with greater risk of stroke.
      Citation: Stroke
      PubDate: 2021-09-02T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034874
       
  • COL4A1 and COL4A2 Duplication Causes Cerebral Small Vessel Disease With
           Recurrent Early Onset Ischemic Strokes

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      Authors: Liina Kuuluvainen Saana Mönkäre Hannaleena Kokkonen Fang Zhao Auli Verkkoniemi-Ahola Johanna Schleutker Anna H. Hakonen Päivi Hartikainen Minna Pöyhönen Liisa Myllykangas Department of Medical; Department of Medical Genetics, Turku University Hospital, Finland (J.S.). Department of Medical Genetics, Turku University Hospital, Finland (S.M.). Neurocenter, Neurology, Kuopio University Hospital, Finland (P.H.).
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-09-02T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033864
       
  • Long-Term Risk of Epilepsy After Pediatric Stroke and Potential Genetic
           Vulnerabilities

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      Authors: Lauren A. Beslow Ingo Helbig Christine K. Fox Division of Neurology; Children’s Hospital of Philadelphia, PA (L.A.B., I.H.). Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia. (L.A.B., I.H.) Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia. (L.A.B.) The Epilepsy NeuroGenetics Initiative (ENGIN), Children’s Hospital of Philadelphia, PA. (I.H.) Department of Biomedical Pediatrics, University of California San Francisco. (C.K.F.)
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-09-02T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.036376
       
  • Switching to Tenecteplase for Stroke Thrombolysis: Real-World Experience
           and Outcomes in a Regional Stroke Network

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      Authors: Karim Mahawish John Gommans Timothy Kleinig Bhavesh Lallu Alicia Tyson Annemarei Ranta Palmerston North Hospital, NZ (K.M.). Hastings Hospital, NZ (J.G.). University of Adelaide, Australia (T.K.). New Plymouth Hospital, NZ (B.L.). Wellington Regional Hospital, NZ (A.T; A.R.). University of Otago (A.R.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Due to practical advantages, increasing trial safety data, recent Australian Guideline endorsement and local population needs we switched to tenecteplase for stroke thrombolysis from alteplase. We describe our change process and real-world outcome data.Methods:Mixed-methods including stakeholder engagement, preimplementation and postimplementation surveys, and assessment of patient treatment rates, metrics, and clinical outcomes preimplementation and postimplementation adjusting regression analyses for age, sex, National Institutes of Health Stroke Scale, premorbid modified Rankin Scale score, and thrombectomy using New Zealand National Stroke Registry data.Results:Preswitch consultation involved stroke and emergency clinicians, pharmacists, national regulatory bodies, and hospital legal teams. All survey responders (90% response rate) supported the proposed change and remained satisfied 12 months postimplementation. Between January 2018 and February 2021, we treated 555 patients with alteplase and 283 with tenecteplase. Patients treated with tenecteplase had greater odds of a favorable modified Rankin Scale using both shift (adjusted odds ratio, 1.60 [95% CI, 1.15–2.22]) and dichotomous analyses (modified Rankin Scale score, 0–2; adjusted odds ratio, 2.17 [95% CI, 1.31–3.59]) and shorter median (interquartile range) door-to-needle time (median, 53 [38–73.5] versus 61 minutes [45–85],P=0.0002). Symptomatic intracranial hemorrhage rates (tenecteplase 1.8% versus 3.4%; adjusted odds ratio, 0.46 [95% CI, 0.13–1.64]), death by day 7 (tenecteplase 7.5% versus 11.8%; adjusted odds ratio, 0.46 [95% CI, 0.21–0.99]), and median (interquartile range) needle to groin time for the 42 transferred regional patients (tenecteplase 155 [113–248] versus 200 [158–266];P=0.27) did not significantly differ.Conclusions:Following stakeholder endorsement, a region-wide switch from alteplase to tenecteplase was successfully implemented. We found evidence of benefit and no evidence of harm.
      Citation: Stroke
      PubDate: 2021-09-01T06:30:01Z
      DOI: 10.1161/STROKEAHA.121.035931
       
  • Effect of Adjusting for Baseline Stroke Severity in the National Inpatient
           Sample

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      Authors: Adam de Havenon Kevin N. Sheth Karen C. Johnston Mohammad Anadani Shadi Yaghi David Tirschwell John Ney Department of Neurology; University of Utah, Salt Lake City (A.d.H.). Department of Neurology, Yale University, New Haven, CT (K.S.). Department of Neurology, University of Virginia, Charlottesville (K.C.J.). Department of Neurology, Washington University (M.A.). Department of Neurology, Brown University, Providence, RI (S.Y.). Department of Neurology, University of Washington (D.T.). Department of Neurology, Boston University, MA (J.N.).
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-08-30T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.035112
       
  • Novel Diffusion-Weighted Imaging Score Showed Good Prognostic Value for
           Acute Basilar Artery Occlusion Following Endovascular Treatment: The
           Pons-Midbrain and Thalamus Score

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      Authors: Lian Liu Meiping Wang Yiming Deng Gang Luo Xuan Sun Ligang Song Xiaochuan Huo Feng Gao Ning Ma Dapeng Mo Zhongrong Miao Department of Interventional Neuroradiology; Beijing Tiantan Hospital, Capital Medical University, Beijing, China (L.L., Y.D., G.L., X.S., L.S., X.H., F.G., N.M., D.M., Z.M.). Department of Epidemiology Health Statistics, School of Public Health, Capital Medical University, Beijing, China (M.W.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Prognostic factors for outcome of endovascular treatment remains to be investigated in patients with acute basilar artery occlusion. We aimed to assess the prognostic value of a novel pretreatment diffusion-weighted imaging score: The Pons-Midbrain and Thalamus (PMT) score.Methods:Eligible patients who underwent endovascular treatment due to acute basilar artery occlusion were reviewed. The PMT score was a diffusion-weighted imaging–based semiquantitative scale in which the infarctions of pons, midbrain, and thalamus were fully considered. The PMT score was assessed as well as the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score and Brain Stem Score. Good outcomes were defined as a modified Rankin Scale score of ≤3 at 90-day and successful reperfusion as Thrombolysis in Cerebral Infarction grades 2b/3. The associations between baseline clinical parameters and good outcomes were evaluated with logistic regression.Results:A total of 107 patients with pretreatment magnetic resonance imaging were included in this cohort. The baseline PMT score (median [interquartile range], 3 [1–5] versus 7 [5–9];P<0.001) and Brain Stem Score (median [interquartile range], 2 [1–4] versus 3 [2–5];P=0.001) were significantly lower in good outcome group; the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score was higher in good outcome group without statistical significance. As a result of receiver operating characteristic curve analyses, the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score showed poor prognostic accuracy for good outcome (area under the curve, 0.60 [95% CI, 0.49–0.71];P=0.081); The baseline PMT score showed significantly better prognostic accuracy for 90-day good outcome than the Brain Stem Score and National Institutes of Health Stroke Scale (area under the curve, 0.80 versus 0.68 versus 0.78,P=0.003). In addition, favorable PMT score <7 (odds ratio, 22.0 [95% CI, 6.0–80.8],P<0.001), Brain Stem Score <3 (odds ratio, 4.65 [95% CI, 2.05–10.55],P<0.001) and baseline National Institutes of Health Stroke Scale <23 (odds ratio, 8.0 [95% CI, 2.5–25.6],P<0.001) were associated with improved good outcome.Conclusions:In patients with acute basilar artery occlusion following endovascular treatment, the pretreatment diffusion-weighted imaging based PMT score showed good prognostic value for clinical outcome.
      Citation: Stroke
      PubDate: 2021-08-30T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.032314
       
  • Ethnic Differences in Informal Caregiving After Stroke

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      Authors: Lewis B. Morgenstern Cecilia N. Hollenhorst Linda C. Gallo Chia-Wei Hsu Sehee Kim River Gibbs Erin Case Lynda D. Lisabeth University of Michigan Medical School, Ann Arbor (L.B.M; C.N.H, L.D.L.). University of Michigan School of Public Health, Ann Arbor (L.B.M, C.-W.H, R.G, E.C, L.D.L.). San Diego State University, CA (L.C.G.). Asian Medical Center, Seoul, South Korea (S.K.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Informal (unpaid) caregiving usually provided by family is important poststroke. We studied whether the prevalence of informal caregiving after stroke differs between Mexican Americans (MAs) and non-Hispanic Whites (NHWs).Methods:Between October 2014 and December 2018, participants in the BASIC (Brain Attack Surveillance in Corpus Christi) project in Nueces County, Texas, were interviewed 90 days after stroke to determine which activities of daily living they required help with and whether family provided informal caregiving. Ethnic differences between MAs and NHWs were determined by logistic regression. The logistic models were stratified by formal (paid) care status. Odds ratios (95% CIs) are reported with NHW as the referent group. Fisher exact tests were used to assess the association of ethnicity with relationship of caregiver and with individual activities of daily living.Results:Eight hundred thirty-one patients answered the caregiving questions. Of these, 242 (29%) received family caregiving (33% of MAs and 23% of NHWs), and 142 (17%) received paid caregiving (21% of MAs and 10% of NHWs). There were no ethnic differences in stroke severity. In logistic regression analyses, among those without formal, paid care, MAs were more likely to have informal caregiving (odds ratio, 1.75 [95% CI, 1.12–2.73]) adjusted for age, National Institutes of Health Stroke Scale, prestroke modified Rankin Scale, and insurance. No ethnic differences in informal care were found among those who had formal care. There were no differences between ethnic groups in which family members provided the informal care. MAs were more likely to require help compared with NHWs for walking (P<0.0001), bathing (P<0.0001), hygiene (P=0.0012), eating (P=0.0004), dressing (P<0.0001), ambulating (P=0.0304), and toileting (P=0.0003).Conclusions:MAs required more help poststroke than NHWs for assistance with activities of daily living. MAs received more help for activities of daily living through informal, unpaid caregiving than NHWs if they were not also receiving formal, paid care. Efforts to help minority and low-resource populations provide stroke care are needed.
      Citation: Stroke
      PubDate: 2021-08-30T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.032740
       
  • Impact of COVID-19 Infection on the Outcome of Patients With Ischemic
           Stroke

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      Authors: Joan Martí-Fàbregas Daniel Guisado-Alonso Raquel Delgado-Mederos Alejandro Martínez-Domeño Luis Prats-Sánchez Marina Guasch-Jiménez Pere Cardona Ana Núñez-Guillén Manuel Requena Marta Rubiera Marta Olivé Alejandro Bustamante Meritxell Gomis Sergio Amaro Laura Llull Xavier Ustrell Gislaine Castilho de Oliveira Laia Seró Manuel Gomez-Choco Luis Mena Joaquín Serena Saima Bashir Viturro Francisco Purroy Mikel Vicente Ana Rodríguez-Campello Angel Ois Esther Catena Maria Carmen Garcia-Carreira Oriol Barrachina Ernest Palomeras Jerzky Krupinski Marta Almeria Josep Zaragoza Patricia Esteve Dolores Cocho Antia Moreira Cecile van Eendenburg Javier Emilio Codas Natalia Pérez de la Ossa Mercè Salvat Pol Camps-Renom Department of Neurology; Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (J.M.-F., D.G.-A., R.D.-M., A.M.-D., L.P.-S., M.G.-J., P.C.-R.). Department of Neurology, Hospital Universitari de Bellvitge, L’Hospitalet del Llobregat, Spain (P.C., A.N.-G.). Department of Neurology, Hospital Universitari Vall d’Hebron, Barcelona, Spain (M. Requena, M. Rubiera, M.O.). Department of Neurology, Hospital Germans Trias i Pujol, Badalona, Spain (A.B., M.G.). Department of Neurology, Hospital Universitari Clinic, Barcelona, Spain (S.A., L.L.). Department of Neurology, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., G.C.d.O., L.S.). Department of Neurology, Hospital de Sant Joan Despí Moisès Broggi, Sant Joan Despí, Spain (M.G.-C., L.M.). Department of Neurology, Hospital Universitari Dr. Josep Trueta, Girona, Spain (J.S., S.B.V.). Stroke Unit, Hospital Universitari Arnau de Vilanova, Lleida, Spain (F.P., M.V.). Department of Neurology, Hospital del Mar, Barcelona, Spain (A.R.-C., A.O., A.M.). Department of Neurology, Hospital comarcal de l’Alt Penedès, Vilafranca del Penedès, Spain (E.C.). Department of Neurology, Hospital Universitari Parc Taulí, Sabadell, Spain (M.C.G.-C., O.B.). Department of Neurology, Hospital de Mataró, Spain (E.P.). Department of Neurology, Hospital Universitari Mútua de Terrassa, Spain (J.K., M.A.). Department of Neurology, Hospital de Tortosa Verge de la Cinta, Spain (J.Z., P.E.). Department of Neurology, Hospital General de Granollers, Spain (D.C.). Department of Neurology, Hospital d’Igualada, Spain (A.M.). Department of Neurology, Hospital de Figueres, Spain (C.v.E.). Department of Neurology, Consorci Sanitari de Terrassa, Spain (J.E.C.). Stroke Program, Agency for Health Quality Assessment of Catalonia, Barcelona, Spain (N.P.d.l.O., M.S.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:We evaluated whether stroke severity, functional outcome, and mortality are different in patients with ischemic stroke with or without coronavirus disease 2019 (COVID-19) infection.Methods:A prospective, observational, multicentre cohort study in Catalonia, Spain. Recruitment was consecutive from mid-March to mid-May 2020. Patients had an acute ischemic stroke within 48 hours and a previous modified Rankin Scale (mRS) score of 0 to 3. We collected demographic data, vascular risk factors, prior mRS score, National Institutes of Health Stroke Scale score, rate of reperfusion therapies, logistics, and metrics. Primary end point was functional outcome at 3 months. Favourable outcome was defined depending on the previous mRS score. Secondary outcome was mortality at 3 months. We performed mRS shift and multivariable analyses.Results:We evaluated 701 patients (mean age 72.3±13.3 years, 60.5% men) and 91 (13%) had COVID-19 infection. Median baseline National Institutes of Health Stroke Scale score was higher in patients with COVID-19 compared with patients without COVID-19 (8 [3–18] versus 6 [2–14],P=0.049). Proportion of patients with a favourable functional outcome was 33.7% in the COVID-19 and 47% in the non-COVID-19 group. However, after a multivariable logistic regression analysis, COVID-19 infection did not increase the probability of unfavourable functional outcome. Mortality rate was 39.3% among patients with COVID-19 and 16.1% in the non-COVID-19 group. In the multivariable logistic regression analysis, COVID-19 infection was a risk factor for mortality (hazard ratio, 3.14 [95% CI, 2.10–4.71];P<0.001).Conclusions:Patients with ischemic stroke and COVID-19 infection have more severe strokes and a higher mortality than patients with stroke without COVID-19 infection. However, functional outcome is comparable in both groups.
      Citation: Stroke
      PubDate: 2021-08-30T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.034883
       
  • Patent Foramen Ovale Closure Decreases the Incidence but Not the Size of
           New Brain Infarction on Magnetic Resonance Imaging: An Analysis of the
           REDUCE Trial

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      Authors: Steven R. Messé Guray Erus Michel Bilello Christos Davatzikos Grethe Andersen Helle K. Iversen Risto O. Roine Christina Sjöstrand John F. Rhodes Lars Søndergaard Scott E. Kasner Department of Neurology; University of Pennsylvania, Philadelphia. (S.R.M., S.E.K.) Department of Radiology (G.E., M.B., C.D.), University of Pennsylvania, Philadelphia. Department of Neurology, Aarhus University, Denmark (G.A.). Department of Neurology, Rigshospitalet, University of Copenhagen, Denmark. (H.K.I.) Department of Cardiology (L.S.), Rigshospitalet, University of Copenhagen, Denmark. Division of Clinical Neurosciences, Turku University Hospital University of Turku, Finland (R.O.R.). Department of Clinical Neurosciences, Karolinska Institutet, Stockholm, Sweden (C.S.). Department of Cardiology, Medical University of South Carolina, Charleston (J.F.R.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Randomized patent foramen ovale closure trials have used open-label end point ascertainment which increases the risk of bias and undermines confidence in the conclusions. The Gore REDUCE trial prospectively performed baseline and follow-up magnetic resonance imaging (MRIs) for all subjects providing an objective measure of the effectiveness of closure.Methods:We performed blinded evaluations of the presence, location, and volume of new infarct on diffusion-weighted imaging of recurrent clinical stroke or new infarct (>3 mm) on T2/fluid attenuated inversion recovery from baseline to follow-up MRI at 2 years, comparing closure to medical therapy alone. We also examined the effect of shunt size and the development of atrial fibrillation on infarct burden at follow-up.Results:At follow-up, new clinical stroke or silent MRI infarct occurred in 18/383 (4.7%) patients who underwent closure and 19/177 (10.7%) medication-only patients (relative risk, 0.44 [95% CI, 0.24–0.81],P=0.02). Clinical strokes were less common in closure patients compared with medically treated patients, 5 (1.3%) versus 12 (6.8%),P=0.001, while silent MRI infarcts were similar, 13 (3.4%) versus 7 (4.0%),P=0.81. There were no differences in number, volumes, and distribution of new infarct comparing closure patients to those treated with medication alone. There were also no differences of number, volumes, and distribution comparing silent infarcts to clinical strokes. Infarct burden was also similar for patients who developed atrial fibrillation and for those with large shunts.Conclusions:The REDUCE trial demonstrates that patent foramen ovale closure prevents recurrent brain infarction based on the objective outcome of new infarcts on MRI. Only clinical strokes were reduced by closure while silent infarctions were similar between study arms, and there were no differences in infarct volume or location comparing silent infarcts to clinical strokes.Registration:URL:https://www.clinicaltrials.gov; Unique identifier: NCT00738894.
      Citation: Stroke
      PubDate: 2021-08-30T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.034451
       
  • Prevention of Patent Foramen Ovale-Related Stroke: An Evolving Concept

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      Authors: Marco R. Di Tullio Division of Cardiology; Department of Medicine, Columbia University Irving Medical Center, New York, NY.
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-08-30T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.035735
       
  • Serious Adverse Events and Their Impact on Functional Outcome in Acute
           Ischemic Stroke in the WAKE-UP Trial

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      Authors: Iris Lettow Märit Jensen Eckhard Schlemm Florent Boutitie Fanny Quandt Bastian Cheng Martin Ebinger Matthias Endres Jochen B. Fiebach Vincent Thijs Robin Lemmens Keith W. Muir Norbert Nighoghossian Salvador Pedraza Claus Z. Simonsen Christian Gerloff Götz Thomalla Klinik und Poliklinik für Neurologie; Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.). Hospices Civils de Lyon, Service de Biostatistique, France (F.B.). Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Germany (M. Ebinger). entrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Germany (M. Ebinger, M. Endres, J.B.F.). Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (M. Endres). Stroke Division, Florey Institute of Neuroscience Mental Health, University of Melbourne, Victoria, Australia (V.T.). Austin Health, Department of Neurology, Australia (V.T.). Department of Neurology, University Hospitals Leuven, Belgium (R.L.). KU Leuven – University of Leuven, Department of Neurosciences, Experimental Neurology, Belgium (R.L.). VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Belgium (R.L.). Institute of Neuroscience & Psychology, University of Glasgow, University Avenue, Glasgow G12 8QQ, United Kingdom (K.W.M.). Department of Stroke Medicine, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, France (N.N.). Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d’Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt - Edifici M2, Italysa (S.P.). Department of Neurology, Aarhus University Hospital, Denmark (C.Z.S.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:During the first days and weeks after an acute ischemic stroke, patients are prone to complications that can influence further treatment, recovery, and functional outcome. In clinical trials, severe complications are recorded as serious adverse events (SAE). We analyzed the effect of SAE on functional outcome and predictors of SAE in the randomized controlled WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke).Methods:We performed a post hoc analysis of WAKE-UP, a multicenter, randomized, placebo-controlled clinical trial of magnetic resonance imaging-guided intravenous thrombolysis with alteplase in patients with acute ischemic stroke and unknown time of onset. Functional outcome was assessed by the modified Rankin Scale 90 days after the stroke. SAE were reported to a central safety desk and recorded and categorized by organ system using Medical Dictionary for Regulatory Activities terminology. We used logistic regression analysis to determine the effect of SAE on functional outcome and linear multiple regression analysis to identify baseline predictors of SAE.Results:Among 503 patients randomized, 199 SAE were reported for n=110 (22%) patients. Of those patients who did suffer a SAE, 20 (10%) had a fatal outcome. Patients suffering from at least one SAE had a lower odds of reaching a favorable outcome (modified Rankin Scale score of 0–1) at 90 days (adjusted odds ratio, 0.36 [95% CI, 0.21–0.61],P<0.001). Higher age (P=0.04) and male sex (P=0.01) were predictors for the occurrence of SAE.Conclusions:SAEs were observed in about one in 5 patients, were more frequent in elderly and male patients and were associated with worse functional outcome. These results may help to assess the risk of SAE in future stroke trials and create awareness for severe complications after stroke in clinical practice.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT01525290 andhttps://eudract.ema.europa.eu; Unique identifier: 2011-005906-32.
      Citation: Stroke
      PubDate: 2021-08-26T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.033425
       
  • First-Pass Effect in Basilar Artery Occlusions: Insights From the
           Endovascular Treatment of Ischemic Stroke Registry

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      Authors: Mathilde Aubertin David Weisenburger-Lile Benjamin Gory Sébastien Richard Raphael Blanc Célina Ducroux Michel Piotin Julien Labreuche Ludovic Lucas Cyril Dargazanli Amel Benali Romain Bourcier Lili Detraz Stéphane Vannier Maud Guillen François Eugene Gregory Walker Ronda Lun Adrien Guenego Arturo Consoli Gaultier Marnat Benjamin Maier Bertrand Lapergue Robert Fahed Interventional Neuroradiology Department; Fondation Rothschild Hospital, Paris, France (M.A., R. Blanc, C. Ducroux, M.P., A.G., B.M., R.F.). Neurovascular Unit, Foch Hospital, Suresnes, France (D.W.-L., B.L.). Department of Diagnostic University of Ottawa, Ontario, Canada (G.W., R.L., R.F.). Department of Medicine, Division of Neurology, Royal Columbian Hospital, New Westminster, University of British Columbia, Canada (G.W.). Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium (A.G.). Department of Neuroradiology, Foch Hospital, Suresnes, France (A.C.). Department of Neuroradiology, Centre Hospitalier Universitaire de Bordeaux, France (G.M.). , for the ETIS Investigators* Michel Piotin Raphael Blanc Hocine Redjem Simon Escalard Jean-Philippe Desilles Gabriele Ciccio Stanislas Smajda Benjamin Maier Solene Hebert François Delvoye Mikael Mazighi Mikael Obadia Candice Sabben Roxanne Peres Ovide Corabianu Thomas de Broucker Didier Smadja Sonia Alamowitch Olivier Ille Eric Manchon Pierre-Yves Garcia Guillaume Taylor Malek Ben Maacha Adrien Wang Serge Evrard Maya Tchikviladze Nadia Ajili Bertrand Lapergue David Weisenburge-Lile Lucas Gorza Géraldine Buard Oguzhan Coskun Arturo Consoli Federico Di Maria Georges Rodesch Sergio Zimatore Morgan Leguen Julie Gratieux Fernando Pico Haja Rakotoharinandrasana Philippe Tassan Roxanna Poll Sylvie Marinier Gaultier Marnat Florent Gariel Xavier Barreau Jérôme Berge Louis Veunac Patrice Menegon Igor Sibon Ludovic Lucas Stéphane Olindo Pauline Renou Sharmila Sagnier Mathilde Poli Sabrina Debruxelles Romain Bourcier Lili Detraz Benjamin Daumas-Duport Pierre-Louis Alexandre Monica Roy Cédric Lenoble Vincent L’allinec, Jean-Baptiste Girot Hubert Desal Benjamin Gory Serge Bracard René Anxionnat Marc Braun Anne-Laure Derelle Romain Tonnelet Liang Liao François Zhu Emmanuelle Schmitt Sophie Planel Sébastien Richard Lisa Humbertjean Gioia Mione Jean-Christophe Lacour Mathieu Bonnerot Nolwenn Riou-Comte Vincent Costalat Caroline Arquizan Cyril Dargazanli Grégory Gascou, Pierre-Henri Lefèvre Imad Derraz Carlos Riquelme Nicolas Gaillard Isabelle Mourand Lucas Corti Eugene Francois Stéphane Vannier Jean-Christophe Ferre Helene Raoult Thomas Ronziere Maria Lassale Christophe Paya Jean-Yves Gauvrit Clément Tracol Sophie Langnier-Lemercier
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:In the settings of thrombectomy, the first-pass effect (FPE), defined by a complete recanalization after one pass with no rescue therapy, has been shown to be associated with an improved outcome. As this phenomenon has been predominantly described in anterior circulation strokes, we aimed to study the prevalence, outcomes, and predictors of FPE in patients with a basilar artery occlusion.Methods:From a prospective multicentric registry, we collected the data of all consecutive basilar artery occlusion patients who underwent thrombectomy and compared the outcomes of patients who achieved FPE and those who did not. We also compared FPE patients with those who achieved a complete recanalization with >1 pass. Finally, a multivariate analysis was performed to determine the predictors of FPE.Results:Data from 280 patients were analyzed in our study, including 84 of 280 patients (30%) with an atheromatous etiology. An FPE was achieved in 93 patients (33.2%), with a significantly higher proportion of good outcomes (modified Rankin Scale score 0-2 at 3 months) and lower mortality than non-FPE patients. An FPE was also associated with improved outcomes compared with patients who went on to have full recanalization with >1 pass. Contact aspiration as first-line strategy was a strong predictor of FPE, whereas baseline antiplatelets and atheromatous etiology were negative predictors.Conclusions:In our study, an FPE was achieved in approximately one-third of patients with a basilar artery occlusion and was associated with improved outcomes. More research is needed to improve devices and techniques to increase the incidence of FPE.Registration:URL:https://www.clinicaltrials.gov; Unique identifier: NCT03776877.
      Citation: Stroke
      PubDate: 2021-08-26T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.030237
       
  • Outcome Following Hemorrhage From Cranial Dural Arteriovenous Fistulae:
           Analysis of the Multicenter International CONDOR Registry

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      Authors: Matthew J. Koch Christopher J. Stapleton Ridhima Guniganti Giuseppe Lanzino Jason Sheehan Ali Alaraj Diederik Bulters Louis Kim W. Christopher Fox Bradley A. Gross Minako Hayakawa J. Marc C. van DijK Robert M. Starke Junichiro Satomi Adam J. Polifka Gregory J. Zipfel Sepideh Amin-Hanjani Department of Neurosurgery, University of Illinois at Chicago, Chicago (M.J.K; A.A, S.A.-H.). Department of Neurosurgery, Massachusetts General Hospital, Boston (C.J.S.). Department of Neurological Surgery, Washington University, St. Louis, MO (R.G, G.J.Z.). Department of Neurosurgery, Mayo Clinic, Rochester, MN. (G.L.) Department of Neurosurgery, University of Virginia, Charlottesville (J.S.). Department of Neurosurgery, University Hospital Southampton, England (D.B.). Department of Neurological Surgery, University of Washington, Seattle, VA (L.K.). Department of Neurosurgery, Mayo Clinic, Jacksonville, FL (W.C.F.). Department of Neurosurgery, University of Pittsburgh, PA (B.A.G.). Department of Radiology, University of Iowa, Iowa City (M.H.). Department of Neurosurgery, University of Groningen, the Netherlands (J.M.C.v.D.). Department of Neurosurgery, University of Miami, FL (R.M.S.). Department of Neurosurgery, Tokushima University, Japan (J.S.). Department of Neurosurgery, University of Florida, Gainesville (A.J.P.). , for the CONDOR Consortium* Gregory J. Zipfel Akash P. Kansagra Ridhima Guniganti Jay F. Piccirillo Hari Raman Kim Lipsey Giuseppe Lanzino Enrico Giordan Waleed Brinjikji Roanna Vine Harry J. Cloft David F. Kallmes Bruce E. Pollock Michael J. Link Jason Sheehan Ching-Jen Chen Mohana Rao Patibandla Dale Ding Thomas Buell Gabriella Paisan Louis Kim Michael R. Levitt Isaac Josh Abecassis R. Michael Meyer Cory Kelly Diederik Bulters Andrew Durnford Jonathan Duffill Adam Ditchfield John Millar Jason Macdonald W. Christopher Fox Adam J. Polifka Dimitri Laurent Brian Hoh Jessica Smith Ashley Lockerman Bradley A. Gross L. Dade Lunsford Brian T. Jankowitz Minako Hayakawa Colin P. Derdeyn Edgar A Samaniego Santiago Ortega Gutierrez David Hasan Jorge A. Roa James Rossen Waldo Guerrero Allen McGruder Sepideh Amin-Hanjani Ali Alaraj Amanda Kwasnicki Fady T. Charbel Victor A. Aletich Linda Rose-Finnell J. Marc C. van Dijk Adriaan R.E. Potgieser Robert M. Starke Eric C Peterson Dileep R Yavagal Samir Sur Stephanie Chen Junichiro Satomi Yoshiteru Tada Yasuhisa Kanematsu Nobuaki Yamamoto Tomoya Kinouchi Masaaki Korai Izumi Yamaguchi Yuki Yamamoto
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Dural arteriovenous fistulae can present with hemorrhage, but there remains a paucity of data regarding subsequent outcomes. We sought to use the CONDOR (Consortium for Dural Arteriovenous Fistula Outcomes Research), a multi-institutional registry, to characterize the morbidity and mortality of dural arteriovenous fistula–related hemorrhage.Methods:A retrospective review of patients in CONDOR who presented with dural arteriovenous fistula–related hemorrhage was performed. Patient characteristics, clinical follow-up, and radiographic details were analyzed for associations with poor outcome (defined as modified Rankin Scale score ≥3).Results:The CONDOR dataset yielded 262 patients with incident hemorrhage, with median follow-up of 1.4 years. Poor outcome was observed in 17.0% (95% CI, 12.3%–21.7%) at follow-up, including a 3.6% (95% CI, 1.3%–6.0%) mortality. Age and anticoagulant use were associated with poor outcome on multivariable analysis (odds ratio, 1.04, odds ratio, 5.1 respectively). Subtype of hemorrhage and venous shunting pattern of the lesion did not affect outcome significantly.Conclusions:Within the CONDOR registry, dural arteriovenous fistula–related hemorrhage was associated with a relatively lower morbidity and mortality than published outcomes from other arterialized cerebrovascular lesions but still at clinically consequential rates.
      Citation: Stroke
      PubDate: 2021-08-26T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.034707
       
  • Baseline Cognitive Impairment in Patients With Asymptomatic Carotid
           Stenosis in the CREST-2 Trial

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      Authors: Ronald M. Lazar Virginia G. Wadley Terina Myers Michael R. Jones Donald V. Heck Wayne M. Clark Randolph S. Marshall Virginia J. Howard Jenifer H. Voeks Jennifer J. Manly Claudia S. Moy Seemant Chaturvedi James F. Meschia Brajesh K. Lal Thomas G. Brott George Howard UAB Evelyn F. McKnight Brain Institute; Department of Neurology, The University of Alabama at Birmingham. (R.M.L., T.M.) Department of Medicine, The University of Alabama at Birmingham. (V.G.W.) Department of Epidemiology, The University of Alabama at Birmingham. (V.J.H.) Cardiology, Baptist Health Lexington, KY (M.R.J.). Diagnostic Radiology, Novant Health, Winston-Salem, NC (D.V.H.). Department of Neurology, Oregon Health & Science University, Portland (W.M.C.). Department of Neurology, Columbia University Irving Medical Center, New York NY. (R.S.M.) Gertrude H. Sergievsky Center Stroke, National Institutes of Health, Bethesda, MD (C.S.M.). Department of Neurology, University of Maryland School of Medicine, Baltimore. (S.C.) Department of Surgery, University of Maryland School of Medicine, Baltimore. (B.K.L.) Department of Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.). Department of Biostatistics, University of Alabama School of Public Health (G.H.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Studies of carotid artery disease have suggested that high-grade stenosis can affect cognition, even without stroke. The presence and degree of cognitive impairment in such patients have not been reported and compared with a demographically matched population-based cohort.Methods:We studied cognition in 1000 consecutive CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) patients, a treatment trial for asymptomatic carotid disease. Cognitive assessment was after randomization but before assigned treatment. The cognitive battery was developed in the general population REGARDS Study (Reasons for Geographic and Racial Differences in Stroke), involving Word List Learning Sum, Word List Recall, and Word List fluency for animal names and the letter F. The carotid stenosis patients were >45 years old with ≥70% asymptomatic carotid stenosis and no history of prevalent stroke. The distribution of cognitive performance for the patients was standardized, accounting for age, race, and education using performance from REGARDS, and after further adjustment for hypertension, diabetes, dyslipidemia, and smoking. Using the Wald Test, we tabulated the proportion ofZscores less than the anticipated deviate for the population-based cohort for representative percentiles.Results:There were 786 baseline assessments. Mean age was 70 years, 58% men, and 52% right-sided stenosis. The overallZscore for patients was significantly below expected for higher percentiles (P<0.0001 for 50th, 75th, and 95th percentiles) and marginally below expected for the 25th percentile (P=0.015). Lower performance was attributed largely to Word List Recall (P<0.0001 for all percentiles) and for Word List Learning (50th, 75th, and 95th percentiles below expected,P≤0.01). The scores for left versus right carotid disease were similar.Conclusions:Baseline cognition of patients with severe carotid stenosis showed below normal cognition compared to the population-based cohort, controlling for demographic and cardiovascular risk factors. This cohort represents the largest group to date to demonstrate that poorer cognition, especially memory, in this disease.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT02089217.
      Citation: Stroke
      PubDate: 2021-08-26T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.032972
       
  • Patients Receiving Extracranial to Intracranial Bypass for Atherosclerotic
           Vessel Occlusion Today Differ Significantly From the COSS Population

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      Authors: Lars Wessels Nils Hecht Peter Vajkoczy Department of Neurosurgery; Center for Stroke research Berlin (CSB), Charité – Universitätsmedizin Berlin, Germany.
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Despite the findings reported in the COSS (Carotid Occlusion Surgery Study), patients with atherosclerotic cerebrovascular disease continue to be referred for superficial temporal artery to middle cerebral artery bypass surgery. Here, we determined how today’s patients differ from the population reported in COSS.Methods:We retrospectively analyzed all patients that were referred to our Department for superficial temporal artery to middle cerebral artery bypass surgery of atherosclerotic cerebrovascular disease following the publication of COSS.Results:Between 2012 and 2019, 179 patients were referred for 186 bypass surgeries. Ninety-one (51%) patients suffered atherosclerotic, unilateral internal carotid occlusion and 88 (49%) atherosclerotic multivessel disease. All patients had received intensive medical management. A single transitory ischemic attack or ischemic stroke within the last 120 days according to the inclusion criteria of COSS occurred in only 36 out of 179 (20%) patients, whereas 27 out of 179 (15%) suffered >1 transitory ischemic attack within 120 days, 109 out of 179 (61%) had recurrent minor ischemic stroke, and 7 out of 179 (4%) were hemodynamically unstable and required blood pressure maintenance. The distribution of symptoms did not differ between atherosclerotic unilateral internal carotid artery occlusion and atherosclerotic multivessel disease (P=0.376) but hemodynamic impairment was significantly greater in atherosclerotic multivessel disease (P<0.001 for atherosclerotic multivessel disease versus atherosclerotic unilateral internal carotid artery occlusion). The overall perioperative stroke rate was 4.3%.Conclusions:Patients referred for flow augmentation surgery today appear to suffer more severe symptoms and vessel occlusion patterns than patients reported in COSS. A new, carefully designed randomized controlled trial appears warranted, considering the still poor prognosis of severe atherosclerotic cerebrovascular disease.
      Citation: Stroke
      PubDate: 2021-08-26T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.033991
       
  • Sonothrombolysis in Patients With Acute Ischemic Stroke With Large Vessel
           Occlusion: An Individual Patient Data Meta-Analysis

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      Authors: Georgios Tsivgoulis Aristeidis H. Katsanos Jürgen Eggers Vincent Larrue Lars Thomassen James C. Grotta Georgios Seitidis Peter D. Schellinger Dimitris Mavridis Andrew Demchuk Vojtech Novotny Carlos A. Molina Areti Angeliki Veroniki Martin Köhrmann Lauri Soinne Andrej Netland Khanevski Andrew D. Barreto Maher Saqqur Theodora Psaltopoulou Keith W. Muir Jochen B. Fiebach Travis Rothlisberger Thomas A. Kent Pitchaiah Mandava Anne W. Alexandrov Andrei V. Alexandrov Department of Neurology; University of Tennessee Health Sciences Center, Memphis (G.T., A.W.A., A.V.A.). Second Department of Neurology, Attikon University Hospital, School of Medicine, National Psychology, University of Glasgow, Queen Elizabeth University Hospital, United Kingdom (K.W.M.). Center for Stroke Research Berlin, Charité-University Medicine Berlin, Germany (J.B.F.). Cerevast Medical, Inc, Bothell, WA (T.R.). Texas A&M Health Science Center-Houston campus, University of Texas (T.A.K.). Department of Neurology, Houston Methodist Hospital, TX (T.A.K.). Michael E. DeBakey VA Medical Center, Houston, TX (P.M.). Department of Neurology, Baylor College of Medicine, Houston, TX (P.M.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Evidence about the utility of ultrasound-enhanced thrombolysis (sonothrombolysis) in patients with acute ischemic stroke (AIS) is conflicting. We aimed to evaluate the safety and efficacy of sonothrombolysis in patients with AIS with large vessel occlusion, by analyzing individual patient data of available randomized-controlled clinical trials.Methods:We included all available randomized-controlled clinical trials comparing sonothrombolysis with or without addition of microspheres (treatment group) to intravenous thrombolysis alone (control group) in patients with AIS with large vessel occlusion. The primary outcome measure was the rate of complete recanalization at 1 to 36 hours following intravenous thrombolysis initiation. We present crude odds ratios (ORs) and ORs adjusted for the predefined variables of age, sex, baseline stroke severity, systolic blood pressure, and onset-to-treatment time.Results:We included 7 randomized controlled clinical trials that enrolled 1102 patients with AIS. A total of 138 and 134 confirmed large vessel occlusion patients were randomized to treatment and control groups respectively. Patients randomized to sonothrombolysis had increased odds of complete recanalization compared with patients receiving intravenous thrombolysis alone (40.3% versus 22.4%; OR, 2.17 [95% CI, 1.03–4.54]; adjusted OR, 2.33 [95% CI, 1.02–5.34]). The likelihood of symptomatic intracranial hemorrhage was not significantly different between the 2 groups (7.3% versus 3.7%; OR, 2.03 [95% CI, 0.68–6.11]; adjusted OR, 2.55 [95% CI, 0.76–8.52]). No differences in the likelihood of asymptomatic intracranial hemorrhage, 3-month favorable functional and 3-month functional independence were documented.Conclusions:Sonothrombolysis was associated with a nearly 2-fold increase in the odds of complete recanalization compared with intravenous thrombolysis alone in patients with AIS with large vessel occlusions. Further study of the safety and efficacy of sonothrombolysis is warranted.
      Citation: Stroke
      PubDate: 2021-08-25T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.030960
       
  • Biomarkers of Coagulation and Inflammation in COVID-19–Associated
           Ischemic Stroke

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      Authors: Charles Esenwa Natalie T. Cheng Jorge Luna Joshua Willey Amelia K. Boehme Kathryn Kirchoff-Torres Daniel Labovitz Ava L. Liberman Peter Mabie Khadean Moncrieffe Ainie Soetanto Andrea Lendaris Johanna Seiden Inessa Goldman David Altschul Ryan Holland Joshua Benton Joseph Dardick Jenelys Fernandez-Torres David Flomenbaum Jenny Lu Avinash Malaviya Nikunj Patel Aureliana Toma Aaron Lord Koto Ishida Jose Torres Thomas Snyder Jennifer Frontera Shadi Yaghi Department of Neurology, Montefiore Medical Center. (C.E; N.T.C, K.K.-T, D.L, A.L.L, P.M, K.M, A.S, A. Lendaris, J.S.) Department of Radiology, Montefiore Medical Center.(I.G.) Department of Neurosurgery, Montefiore Medical Center. (D.A, R.H.) Department of Neurology, Columbia University Medical Center (J.L, J.W, A.K.B.). Albert Einstein College of Medicine (J.B, J.D, J.F.T, D.F, J.L, A.M, N.P, A.T.). Department of Neurology, New York University School of Medicine (A. Lord, K.I, J.T, T.S, J.F, S.Y.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:We sought to determine if biomarkers of inflammation and coagulation can help define coronavirus disease 2019 (COVID-19)–associated ischemic stroke as a novel acute ischemic stroke (AIS) subtype.Methods:We performed a machine learning cluster analysis of common biomarkers in patients admitted with severe acute respiratory syndrome coronavirus 2 to determine if any were associated with AIS. Findings were validated using aggregate data from 3 large healthcare systems.Results:Clustering grouped 2908 unique patient encounters into 4 unique biomarker phenotypes based on levels of c-reactive protein, D-dimer, lactate dehydrogenase, white blood cell count, and partial thromboplastin time. The most severe cluster phenotype had the highest prevalence of AIS (3.6%,P<0.001), in-hospital AIS (53%,P<0.002), severe AIS (31%,P=0.004), and cryptogenic AIS (73%,P<0.001). D-dimer was the only biomarker independently associated with prevalent AIS with quartile 4 having an 8-fold higher risk of AIS compared to quartile 1 (P=0.005), a finding that was further corroborated in a separate cohort of 157 patients hospitalized with COVID-19 and AIS.Conclusions:COVID-19–associated ischemic stroke may be related to COVID-19 illness severity and associated coagulopathy as defined by increasing D-dimer burden.
      Citation: Stroke
      PubDate: 2021-08-25T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.035045
       
  • Hypertension Management in Stroke Prevention: Time to Consider Primary
           Aldosteronism

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      Authors: Josephine McCarthy Jun Yang Ben Clissold Morag J. Young Peter J. Fuller Thanh Phan Department of Endocrinology; Eastern Health, Box Hill, Australia (J.M.). Centre for Endocrinology Diabetes Institute, Melbourne, Australia (M.J.Y.).
      Abstract: Stroke, Ahead of Print.
      Primary aldosteronism confers a higher risk of stroke, atrial fibrillation, and cardiovascular disease than blood pressure matched essential hypertension. It is the most common endocrine cause of secondary hypertension with prevalence estimates of up to 13% in primary care and 30% in referral centers around the world. Unlike essential hypertension, primary aldosteronism has targeted medical treatment and potentially curative surgical solutions which can ameliorate the associated cardiovascular risks. This narrative review highlights an evidence gap in the optimal diagnosis and targeted treatment of primary aldosteronism in secondary stroke prevention. Over half of the patients suffering a stroke have blood pressure in the hypertensive range and less than a third achieve optimal blood pressure control. There are no guideline recommendations to test for primary aldosteronism in these patients, although up to 30% of patients with resistant hypertension may have this disease. The accurate diagnosis of primary aldosteronism could significantly improve blood pressure, simplify the medication regimen and reduce the overall cardiovascular risk in these patients. The challenges associated with screening for primary aldosteronism following stroke may be overcome by novel blood tests which are less affected by antihypertensive medications routinely used in stroke care. Approximately one-quarter of all strokes occur in patients who have previously had a stroke. Modifying hypertension, the leading modifiable risk factor, would, therefore, have significant public health implications. As clinicians, we must increase our awareness of primary aldosteronism in patients with stroke, particularly in those with resistant hypertension, to enable targeted therapy and reduce the risk of stroke recurrence.
      Citation: Stroke
      PubDate: 2021-08-25T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.033990
       
  • Endovascular Treatment for Acute Stroke in Cerebral Amyloid Angiopathy

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      Authors: Johannes M. Weller Simon Jonas Enkirch Christopher Bogs Tim Bastian Braemswig Milani Deb-Chatterji Fee Keil Christine Kindler Sarah Maywald Markus D. Schirmer Sebastian Stösser Laszlo Solymosi Christian H. Nolte Felix J. Bode Gabor C. Petzold Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Germany. (J.M.W; C.B, C.K, S.M, S.S, F.J.B, G.C.P.) Department of Neuroradiology, University Hospital Bonn, Germany. (S.J.E, M.D.S, L.S.) Department of Neurology, Charité–Universitätsmedizin Berlin, Germany (T.B.B, C.H.N.). Berlin Institute of Health (BIH), Germany (T.B.B.). Department of Neurology, University Hospital Hamburg-Eppendorf, Germany (M.D.-C.). Department of Neuroradiology, Frankfurt University, Germany (F.K.). German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany (G.C.P.). , on behalf of the GSR-ET Investigators A. Alegiani C. Bangard D. Behme J. Berrouschot T. Boeckh-Behrens G. Bohner A. Bormann M. Braun M. Dichgans F. Dorn B. Eckert U. Ernemann J. Fiehler C. Gerloff K. Gröschel G.F. Hamann K.H. Henn A. Kastrup L. Kellert C. Kraemer L. Krause J. Liman A. Ludolph M. Petersen W. Pfeilschifter S. Poli A. Reich C. Roth J. Röther E. Siebert F. Stögbauer G. Thomalla S. Thonke S. Tiedt C. Trumm T. Uphaus M. Wiesmann S. Wunderlich S. Zweynert
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:We aimed to compare outcome of endovascular thrombectomy in acute ischemic stroke in patients with and without cerebral amyloid angiopathy (CAA).Methods:We included patients with and without possible or probable CAA based on the modified Boston criteria from an observational multicenter cohort of patients with acute ischemic stroke and endovascular thrombectomy, the German Stroke Registry Endovascular Treatment trial. We analyzed baseline characteristics, procedural parameters, and functional outcome after 90 days.Results:Twenty-eight (17.3%) of 162 acute ischemic stroke patients were diagnosed with CAA based on iron-sensitive magnetic resonance imaging performed before endovascular thrombectomy. CAA patients were less likely to have a good 90-day outcome (14.3 versus 37.8%). National Institutes of Health Stroke Scale score (adjusted odds ratio, 0.88;P<0.001), successful recanalization (adjusted odds ratio 6.82;P=0.005), and CAA (adjusted odds ratio 0.28;P=0.049) were independent outcome predictors. Intravenous thrombolysis was associated with an increased rate of good outcome (36.3% versus 0%,P=0.031) in CAA.Conclusions:Endovascular thrombectomy with or without thrombolysis appears beneficial in acute ischemic stroke patients with possible or probable CAA, but is associated with a worse functional outcome.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT03356392.
      Citation: Stroke
      PubDate: 2021-08-20T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.033014
       
  • Serum Zinc Levels and Incidence of Ischemic Stroke: The Reasons for
           Geographic and Racial Differences in Stroke Study

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      Authors: Lindsey Mattern Cheng Chen Leslie A. McClure John Brockman Mary Cushman Suzanne Judd Ka Kahe Department of Anthropology; College of Arts Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA (L.A.M.). Department of Chemistry, University of Missouri, Columbia (J.B.). Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington (M.C.). Department of Biostatistics, School of Public Health, University of Alabama at Birmingham (S.J.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Despite zinc’s role as an antioxidant and anti-inflammatory agent, prospective studies relating zinc levels to ischemic stroke risk are lacking. To examine the association between serum zinc levels and incidence of ischemic stroke in a US population.Methods:Using a case–cohort study nested within the Reasons for Geographic and Racial Differences in Stroke cohort, participants were randomly selected from the Reasons for Geographic and Racial Differences in Stroke cohort to generate a sub-cohort (n=2346). All incident ischemic stroke cases as of September 2012 (n=660) were included, with 62 incident cases overlapping in the sub-cohort. Serum zinc levels were measured at baseline. Barlow-weighted Cox’s proportional hazards regression models were used to calculate multivariable-adjusted hazard ratios and the corresponding 95% CI of ischemic stroke by serum zinc levels.Results:The median zinc level for the sub-cohort was 121.19 µg/dL (interquartile range, 104.86–140.39 µg/dL). Serum zinc levels were inversely associated with incidence of ischemic stroke after adjustment for potential confounders (quartile 4 versus quartile 1: hazard ratio, 0.78 [95% CI, 0.61–0.98],P=0.03 for trend). When stratified by prespecified factors (sex, race, region), only sex showed a significant modification (P=0.03 for interaction). The inverse association was more pronounced among females (quartile 4 versus quartile 1: hazard ratio, 0.58 [95% CI, 0.41–0.84],P<0.01 for trend) than males (quartile 4 versus quartile 1: hazard ratio, 1.08 [95% CI, 0.78–1.51],P=0.92 for trend).Conclusions:Serum zinc concentration was inversely associated with incidence of ischemic stroke, especially among women, indicating that low zinc levels may be a risk factor for ischemic stroke.
      Citation: Stroke
      PubDate: 2021-08-20T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.033187
       
  • Natural History and Clinical Outcomes of Paravertebral Arteriovenous
           Shunts

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      Authors: Yueshan Feng Jiaxing Yu Jiankun Xu Chuan He Lisong Bian Guilin Li Ming Ye Peng Hu Liyong Sun Nan Jiang Feng Ling Tao Hong Hongqi Zhang Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F; J.Y, J.X, C.H, G.L, M.Y, P.H, L.S, N.J, F.L, T.H, H.Z.). International Neuroscience Institute, Beijing, China (Y.F, J.Y, J.X, C.H, G.L, M.Y, P.H, L.S, N.J, F.L, T.H, H.Z.). Department of Neurosurgery, Beijing Haidian Hospital, China (L.B.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Paravertebral arteriovenous shunts (PVAVSs) are rare. Whether the intradural venous system is involved in drainage may lead to differences in clinical characteristics through specific pathophysiological mechanisms. This study aims to comprehensively evaluate the natural history and clinical outcomes of PVAVSs with or without intradural drainage.Methods:Sixty-four consecutive patients with PVAVSs from 2 institutes were retrospectively reviewed. Lesions were classified as type A (n=28) if the intradural veins were involved in drainage; otherwise, they were classified as type B (n=36). The clinical course from initial presentation to the last follow-up was analyzed.Results:The patients with type A shunts were older at presentation (52.5 versus 35.5 years,P<0.0001) and more likely to have lower spinal segments affected than patients with type B PVAVSs (67.8% versus 13.9%,P=0.00006). After presentation, the deterioration rates related to gait and sphincter dysfunction were significantly higher in patients with type A than type B shunts (gait dysfunction: 71.8%/y versus 17.0%/y,P=0.0006; sphincter dysfunction: 63.7%/y versus 11.3%/y,P=0.0002). According to the angiogram at the end of the latest treatment, 79% of type A and 75% of type B PVAVSs were completely obliterated. If the lesions were partially obliterated, a significantly higher clinical deterioration rate was observed in patients with type A shunts than those with type B shunts (69.9%/y versus 3.2%/y,P=0.0253).Conclusions:Type A PVAVSs feature rapid progressive neurological deficits; therefore, early clinical intervention is necessary. For complex lesions that cannot be completely obliterated, surgical disconnection of all refluxed radicular veins is suggested.
      Citation: Stroke
      PubDate: 2021-08-20T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.033963
       
  • Corticospinal Tract Microstructure Correlates With Beta Oscillatory
           Activity in the Primary Motor Cortex After Stroke

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      Authors: Robert Schulz Marlene Bönstrup Stephanie Guder Jingchun Liu Benedikt Frey Fanny Quandt Lutz A. Krawinkel Bastian Cheng Götz Thomalla Christian Gerloff Department of Neurology, University Medical Centre Hamburg-Eppendorf, Germany (R.S; M.B, S.G, B.F, F.Q, L.A.K, B.C, G.T, C.G.). Department of Neurology, University Medical Centre, Leipzig, Germany (M.B.). Department of Radiology, Tianjin Medical University General Hospital, China (J.L.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Cortical beta oscillations are reported to serve as robust measures of the integrity of the human motor system. Their alterations after stroke, such as reduced movement-related beta desynchronization in the primary motor cortex, have been repeatedly related to the level of impairment. However, there is only little data whether such measures of brain function might directly relate to structural brain changes after stroke.Methods:This multimodal study investigated 18 well-recovered patients with stroke (mean age 65 years, 12 males) by means of task-related EEG and diffusion-weighted structural MRI 3 months after stroke. Beta power at rest and movement-related beta desynchronization was assessed in 3 key motor areas of the ipsilesional hemisphere that are the primary motor cortex (M1), the ventral premotor area and the supplementary motor area. Template trajectories of corticospinal tracts (CST) originating from M1, premotor cortex, and supplementary motor area were used to quantify the microstructural state of CST subcomponents. Linear mixed-effects analyses were used to relate tract-related mean fractional anisotropy to EEG measures.Results:In the present cohort, we detected statistically significant reductions in ipsilesional CST fractional anisotropy but no alterations in EEG measures when compared with healthy controls. However, in patients with stroke, there was a significant association between both beta power at rest (P=0.002) and movement-related beta desynchronization (P=0.003) in M1 and fractional anisotropy of the CST specifically originating from M1. Similar structure-function relationships were neither evident for ventral premotor area and supplementary motor area, particularly with respect to their CST subcomponents originating from premotor cortex and supplementary motor area, in patients with stroke nor in controls.Conclusions:These data suggest there might be a link connecting microstructure of the CST originating from M1 pyramidal neurons and beta oscillatory activity, measures which have already been related to motor impairment in patients with stroke by previous reports.
      Citation: Stroke
      PubDate: 2021-08-20T09:00:03Z
      DOI: 10.1161/STROKEAHA.121.034344
       
  • Association Between Excess Leisure Sedentary Time and Risk of Stroke in
           Young Individuals

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      Authors: Raed A. Joundi Scott B. Patten Jeanne V.A. Williams Eric E. Smith Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Canada. (R.A.J; E.E.S.) Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Canada. (S.B.P, J.V.A.W, R.A.J, E.E.S.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The association between physical activity (PA) and lower risk of stroke is well established, but the relationship between leisure sedentary time and stroke is less well studied.Methods:We used 9 years of the Canadian Community Health Survey between 2000 and 2012 to create a cohort of healthy individuals without prior stroke, heart disease, or cancer. We linked to hospital records to determine subsequent hospitalization or emergency department visit for stroke until December 31, 2017. We quantified the association between self-reported leisure sedentary time (categorized as <4, 4 to <6, 6 to <8, and 8+ hours/day) and risk of stroke using Cox regression models and competing risk regression, assessing for modification by PA, age, and sex and adjusting for demographic, vascular, and social factors.Results:There were 143 180 people in our cohort and 2965 stroke events in follow-up. Median time from survey response to stroke was 5.6 years. There was a 3-way interaction between leisure sedentary time, PA, and age. The risk of stroke with 8+ hours of sedentary time was significantly elevated only among individuals <60 years of age who were in the lowest PA quartile (fully adjusted hazard ratio, 4.50 [95% CI, 1.64–12.3]). The association was significant across multiple sensitivity analyses, including adjustment for mood disorders and when accounting for the competing risk of death.Conclusions:Excess leisure sedentary time of 8+ hours/day is associated with increased risk of long-term stroke among individuals <60 years of age with low PA. These findings support efforts to enhance PA and reduce sedentary time in younger individuals.
      Citation: Stroke
      PubDate: 2021-08-19T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034985
       
  • Optimizing Emergency Stroke Transport Strategies Using Physiological
           Models

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      Authors: Daniel A. Paydarfar David Paydarfar Peter J. Mucha Joshua Chang Carolina Center for Interdisciplinary Applied Mathematics; Department of Mathematics, University of North Carolina, Chapel Hill. (D.A.P., P.J.M.) Department of Neurology, Dell Medical School, Mulva Clinic for the Neurosciences Sciences, The University of Texas at Austin (J.C.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The criteria for choosing between drip and ship and mothership transport strategies in emergency stroke care is widely debated. Although existing data-driven probability models can inform transport decision-making at an epidemiological level, we propose a novel mathematical, physiologically derived framework that provides insight into how patient characteristics underlying infarct core growth influence these decisions.Methods:We represent the physiology of time-dependent infarct core growth within an ischemic penumbra as an exponential function with consideration to rate-determining collateral blood flow. Monte Carlo methods generate distributions of infarct core volumes, which are translated to distributions of 90-day modified Rankin Scale scores. We apply the model to a stroke network that serves rural Bastrop County and urban Travis County by simulating transport strategies from thousands of potential patient pickup locations. In every pickup location, the simulation yields a distribution of outcomes corresponding to each transport strategy. A 2-sample Kolmogorov-Smirnov test and Studentttest determine which transport strategy provides a significantly better probability of a good outcome for a given pickup location in each respective county (P<0.01).Results:In Travis County, drip and ship provides significantly better probabilities of a good outcome in 24.0% of the pickup locations, while 59.8% favor mothership. In Bastrop County, 11.3% of the pickup locations favor drip and ship, while only 7.1% favor mothership. The remaining pickup locations in each county are not statistically significant in either direction. We also reveal how differing rates of infarct core growth, the application of bypass policies, and the use of large vessel occlusion field tests impact these results.Conclusions:Modeling stroke physiology enables the use of clinically relevant metrics for determining comparative significance between drip and ship and mothership in a given geography. This formalism can help understand and inform emergency medical service transport decision-making, as well as regional bypass policies.
      Citation: Stroke
      PubDate: 2021-08-19T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.031633
       
  • Dual Antiplatelet Therapy Using Cilostazol With Aspirin or Clopidogrel:
           Subanalysis of the CSPS.com Trial

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      Authors: Haruhiko Hoshino Kazunori Toyoda Katsuhiro Omae Noriyuki Ishida Shinichiro Uchiyama Kazumi Kimura Nobuyuki Sakai Yasushi Okada Kortaro Tanaka Hideki Origasa Hiroaki Naritomi Kiyohiro Houkin Keiji Yamaguchi Masanori Isobe Kazuo Minematsu Masayasu Matsumoto Teiji Tominaga Hidekazu Tomimoto Yasuo Terayama Satoshi Yasuda Takenori Yamaguchi Department of Neurology; Tokyo Saiseikai Central Hospital, Japan (H.H.). Department of Cerebrovascular Medicine, National Cerebral Clinical Epidemiology, University of Toyama, Japan. (H.O.) Department of Neurology, Senri Chuo Hospital, Toyonaka, Japan (H.N.). Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan (K.H.). Department of Neurology, Ichinomiya Nishi Hospital, Ichinomiya, Japan (K.Y.). Department of Neurosurgery, Kushiro Rosai Hospital, Kushiro, Japan (M.I.). Headquarters of the Iseikai Medical Corporation, Osaka, Japan (K.M.). Department of Neurology, Sakai City Medical Center, Osaka, Japan (M.M.). Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan. (T.T.) Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan. (S.Y.) Department of Neurology, Graduate School of Medicine, Mie University, Tsu, Japan (H.T.). Neurological Institute, Shonan Keiiku Hospital, Fujisawa, Japan (Y.T.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Although dual antiplatelet therapy (DAPT) with aspirin and clopidogrel reduces the recurrence of ischemic stroke while significantly increasing the bleeding events compared with monotherapy, the CSPS.com trial (Cilostazol Stroke Prevention Study combination) showed that DAPT using cilostazol was more effective without the bleeding risk. In the CSPS.com trial, aspirin or clopidogrel was used as the underlying antiplatelet drug. The effectiveness and safety of each combination were examined and clarified.Methods:In the CSPS.com trial, a multicenter, open-label, randomized controlled study, patients with high-risk, noncardioembolic ischemic stroke 8 to 180 days after onset treated with aspirin or clopidogrel alone at the discretion of the physician in charge were recruited. Patients were randomly assigned to receive either monotherapy or DAPT using cilostazol and followed for 0.5 to 3.5 years. The primary efficacy outcome was first recurrence of ischemic stroke. The safety outcome was severe or life-threatening bleeding. The analysis was based on the underlying antiplatelet agents.Results:A total of 763 patients taking aspirin and 1116 taking clopidogrel were included in the intention-to-treat analysis. Although the clopidogrel group had more risk factors than the aspirin group, the primary efficacy outcome and safety outcome did not differ significantly between the 2 groups. In the aspirin group, the primary efficacy outcome and safety outcome did not differ significantly between the DAPT group and the aspirin-monotherapy group. In the clopidogrel group, the primary end point occurred at a rate of 2.31 per 100 patient-years in the DAPT group and 5.19 per 100 patient-years in the clopidogrel-monotherapy group (hazard ratio, 0.447 [95% CI, 0.258–0.774]). Safety outcome did not differ significantly between groups (0.51 per 100 patient-years versus 0.71 per 100 patient-years, respectively; hazard ratio, 0.730 [95% CI, 0.206–2.588]).Conclusions:The combination of cilostazol and clopidogrel significantly reduced the recurrence of ischemic stroke without increasing the bleeding risk in noncardioembolic, high-risk patients.REGISTRATION:URL:http://www.clinicaltrials.gov; Unique identifier: NCT01995370. URL:https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000012180.
      Citation: Stroke
      PubDate: 2021-08-18T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034378
       
  • Rare NOTCH3 Variants in a Chinese Population-Based Cohort and Its
           Relationship With Cerebral Small Vessel Disease

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      Authors: Jing-Yi Liu Ming Yao Yi Dai Fei Han Fei-Fei Zhai Ding-Ding Zhang Li-Xin Zhou Jun Ni Shu-Yang Zhang Li-Ying Cui Yi-Cheng Zhu Department of Neurology; Peking Union Medical College Hospital, Peking Union Medical College Chinese Academy of Medical Science, Beijing, China (S.-Y.Z.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Researches on rare variants ofNOTCH3in the general Chinese population are lacking. This study aims to describe the spectrum of rareNOTCH3variants by whole-exome sequencing in a Chinese community-based cohort and to investigate the association between rareNOTCH3variants and age-related cerebral small vessel disease.Methods:The cross-sectional study comprised 1065 participants who underwent whole-exome sequencing and brain magnetic resonance imaging.NOTCH3variants with minor allele frequency<1% in all 4 public population databases (1000 Genomes, ESP6500siv2_ALL, GnomAD_ALL, and GnomAD_EAS) were defined as rare variants. Multivariable linear and logistic regressions were used to investigate the associations between rareNOTCH3variants and volume of white matter hyperintensities and cerebral small vessel disease burden. Clinical and imaging characteristics of rareNOTCH3variant carriers were summarized.Results:Sixty-five rareNOTCH3variants were identified in 147 of 1065 (13.8%) participants, including 57 missense single nucleotide polymorphisms (SNPs), 5 SNPs in splice branching sites, and 3 frameshift deletions. A significantly higher volume of white matter hyperintensities and heavier burden of cerebral small vessel disease was found in carriers of rareNOTCH3EGFr (epidermal growth factor-like repeats)-involving variants, but not in carriers of EGFr-sparing variants. The carrying rate of rare EGFr-involvingNOTCH3variants in participants with dementia or stroke was significantly higher than those without dementia or stroke (12.4% versus 6.6%,P=0.041). Magnetic resonance imaging signs suggestive of CADASIL were found in 3.4% (5/145) rare EGFr cysteine-sparingNOTCH3variant carriers but not in 2 cysteine-alteringNOTCH3variant carriers.Conclusions:Carriers of rareNOTCH3variants involving the EGFr domain may be genetically predisposed to age-related cerebral small vessel disease in the general Chinese population.
      Citation: Stroke
      PubDate: 2021-08-18T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.032265
       
  • Drugs Associated With Ischemic Stroke: A Review for Clinicians

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      Authors: João Pedro Marto Davide Strambo Francoise Livio Patrik Michel Department of Clinical Neurosciences, Stroke Centre, Neurology Service, Lausanne University Hospital, Switzerland. (J.P.M; D.S, P.M.) Service of Clinical Pharmacology, Department of Laboratories, Lausanne University Hospital, Switzerland. (F.L.) Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (J.P.M.).
      Abstract: Stroke, Ahead of Print.
      Certain drugs may increase the risk of ischemic stroke (IS). Our goal was to review associations between frequently used drugs and IS. We created an initial list of frequently used drugs to search Pubmed/MEDLINE from 1966 to 2020 and reviewed phase III and IV data, case series, and drug authorities’ safety warnings to assess a potential association with IS. Drugs were grouped according to the World Health Organization Anatomical Therapeutic Chemical Classification System. Predefined criteria were applied to establish a level of evidence for an association, from A (high level of evidence of association) to E (high level of evidence of absence of association). In addition, we assessed relative risks and reviewed potential mechanisms of IS facilitation. We assessed 81 drugs or drug classes from 11 World Health Organization Anatomical Therapeutic Chemical Groups. We identified a high level of association for erythropoietin, combined contraceptives, oral estrogen replacement therapy, bevacizumab, tamoxifen, and antipsychotics and a moderate level for ponatinib, nilotinib, darunavir, and gonadotropin-releasing hormone agonists. Drug dose and treatment duration may modify the risk. For a substantial number of drugs, we found no association, and for others, there were insufficient data to categorize risk. We identified a high level of association of IS with a limited number of drugs, a potential association with some, and a lack of data for others. The summarized information may help clinicians to estimate the contribution of a drug to an IS, to better assess drug benefit-risk ratios, and to support decisions about using specific drugs.
      Citation: Stroke
      PubDate: 2021-08-18T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033272
       
  • Cerebral Edema in Patients With Large Hemispheric Infarct Undergoing
           Reperfusion Treatment: A HERMES Meta-Analysis

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      Authors: Felix C. Ng Nawaf Yassi Gagan Sharma Scott B. Brown Mayank Goyal Charles B.L.M. Majoie Tudor G. Jovin Michael D. Hill Keith W. Muir Jeffrey L. Saver Francis Guillemin Andrew M. Demchuk Bijoy K. Menon Luis San Roman David S. Liebeskind Philip White Diederik W.J. Dippel Antoni Davalos Serge Bracard Peter J. Mitchell Michael J. Wald Stephen M. Davis Kevin N. Sheth W. Taylor Kimberly Bruce C.V. Campbell Department of Medicine; University Hospital of Nancy, France (S.B.). Biogen, Cambridge, MA (M.J.W.). Department of Neurology, Yale-New Haven Hospital, CT (K.N.S.). Centre for Genomic Medicine, Department of Neurology, Massachusetts General Hospital, Boston (W.T.K.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Whether reperfusion into infarcted tissue exacerbates cerebral edema has treatment implications in patients presenting with extensive irreversible injury. We investigated the effects of endovascular thrombectomy and reperfusion on cerebral edema in patients presenting with radiological evidence of large hemispheric infarction at baseline.Methods:In a systematic review and individual patient-level meta-analysis of 7 randomized controlled trials comparing thrombectomy versus medical therapy in anterior circulation ischemic stroke published between January 1, 2010, and May 31, 2017 (Highly Effective Reperfusion Using Multiple Endovascular Devices collaboration), we analyzed the association between thrombectomy and reperfusion with maximal midline shift (MLS) on follow-up imaging as a measure of the space-occupying effect of cerebral edema in patients with large hemispheric infarction on pretreatment imaging, defined as diffusion-magnetic resonance imaging or computed tomography (CT)-perfusion ischemic core 80 to 300 mL or noncontrast CT-Alberta Stroke Program Early CT Score ≤5. Risk of bias was assessed using the Cochrane tool.Results:Among 1764 patients, 177 presented with large hemispheric infarction. Thrombectomy and reperfusion were associated with functional improvement (thrombectomy common odds ratio =2.30 [95% CI, 1.32–4.00]; reperfusion common odds ratio =4.73 [95% CI, 1.66–13.52]) but not MLS (thrombectomy β=−0.27 [95% CI, −1.52 to 0.98]; reperfusion β=−0.78 [95% CI, −3.07 to 1.50]) when adjusting for age, National Institutes of Health Stroke Score, glucose, and time-to-follow-up imaging. In an exploratory analysis of patients presenting with core volume >130 mL or CT-Alberta Stroke Program Early CT Score ≤3 (n=76), thrombectomy was associated with greater MLS after adjusting for age and National Institutes of Health Stroke Score (β=2.76 [95% CI, 0.33–5.20]) but not functional improvement (odds ratio, 1.71 [95% CI, 0.24–12.08]).Conclusions:In patients presenting with large hemispheric infarction, thrombectomy and reperfusion were not associated with MLS, except in the subgroup with very large core volume (>130 mL) in whom thrombectomy was associated with increased MLS due to space-occupying ischemic edema. Mitigating cerebral edema-mediated secondary injury in patients with very large infarcts may further improve outcomes after reperfusion therapies.
      Citation: Stroke
      PubDate: 2021-08-13T09:00:03Z
      DOI: 10.1161/STROKEAHA.120.033246
       
  • Mediterranean Diet Reduces Atherosclerosis Progression in Coronary Heart
           Disease: An Analysis of the CORDIOPREV Randomized Controlled Trial

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      Authors: Jose Jimenez-Torres Juan F. Alcalá-Diaz Jose D. Torres-Peña Francisco M. Gutierrez-Mariscal Ana Leon-Acuña Purificación Gómez-Luna Carolina Fernández-Gandara Gracia M. Quintana-Navarro Jose C. Fernandez-Garcia Pablo Perez-Martinez Jose M. Ordovas Javier Delgado-Lista Elena M. Yubero-Serrano Jose Lopez-Miranda Unidad de Gestión Clinica Medicina Interna; Lipids Nutrition, Regional University Hospital of Málaga, Instituto de Investigación Biomédica de Malaga (IBIMA), Spain (J.C.F.-G.). Jean Mayer US Department of Agriculture Human Nutrition Research Center on Aging, Tufts University School of Medicine, Boston, MA (J.M.O.). IMDEA-Food Institute, CEI UAM + CSIC, Madrid, Spain (J.M.O.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Lifestyle and diet affect cardiovascular risk, although there is currently no consensus about the best dietary model for the secondary prevention of cardiovascular disease. The CORDIOPREV study (Coronary Diet Intervention With Olive Oil and Cardiovascular Prevention) is an ongoing prospective, randomized, single-blind, controlled trial in 1002 coronary heart disease patients, whose primary objective is to compare the effect of 2 healthy dietary patterns (low-fat rich in complex carbohydrates versus Mediterranean diet rich in extra virgin olive oil) on the incidence of cardiovascular events. Here, we report the results of one secondary outcome of the CORDIOPREV study. Thus, to evaluate the efficacy of these diets in reducing cardiovascular disease risk. Intima-media thickness of both common carotid arteries (IMT-CC) was ultrasonically assessed bilaterally. IMT-CC is a validated surrogate for the status and future cardiovascular disease risk.Methods:From the total participants, 939 completed IMT-CC evaluation at baseline and were randomized to follow a Mediterranean diet (35% fat, 22% monounsaturated fatty acids, <50% carbohydrates) or a low-fat diet (28% fat, 12% monounsaturated fatty acids, >55% carbohydrates) with IMT-CC measurements at 5 and 7 years. We also analyzed the carotid plaque number and height.Results:The Mediterranean diet decreased IMT-CC at 5 years (−0.027±0.008 mm;P<0.001), maintained at 7 years (−0.031±0.008 mm;P<0.001), compared to baseline. The low-fat diet did not modify IMT-CC. IMT-CC and carotid plaquemaxheight were higher decreased after the Mediterranean diet, compared to the low-fat diet, throughout follow-up. Baseline IMT-CC had the strongest association with the changes in IMT-CC after the dietary intervention.Conclusions:Long-term consumption of a Mediterranean diet rich in extravirgin olive oil, if compared to a low-fat diet, was associated with decreased atherosclerosis progression, as shown by reduced IMT-CC and carotid plaque height. These findings reinforce the clinical benefits of the Mediterranean diet in the context of secondary cardiovascular prevention.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT00924937.
      Citation: Stroke
      PubDate: 2021-08-10T09:00:01Z
      DOI: 10.1161/STROKEAHA.120.033214
       
  • Incidence Rates and Case-Fatality Rates of Cerebral Vein Thrombosis: A
           Population-Based Study

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      Authors: Emanuele Rezoagli Aldo Bonaventura Jonathan M. Coutinho Alessandra Vecchié Vera Gessi Roberta Re Alessandro Squizzato Fulvio Pomero Matteo Bonzini Walter Ageno Francesco Dentali Department of Medicine; Community Health, University of Milan, IRCCS Policlinico Fundation, Italy (M.B.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Cerebral vein thrombosis (CVT) incidence is estimated to be >10 per 1 000 000 per year. Few population-based studies investigating case-fatality rates (CFRs) and pyogenic/nonpyogenic CVT incidence are available. We assessed trends in CVT incidence between 2002 and 2012, as well as adjusted in-hospital CFRs and incidence of hospital admissions for pyogenic/nonpyogenic CVT in a large Northwestern Italian epidemiological study.Methods:Primary and secondary discharge diagnoses of pyogenic/nonpyogenic CVT were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes 325, 671.5, and 437.6. Age, sex, vital status at discharge, length of hospital stay, and up to 5 secondary discharge diagnoses were collected. Concomitant presence of intracerebral hemorrhage (ICH) was registered, and comorbidities were assessed through the Charlson comorbidity index.Results:A total of 1718 patients were hospitalized for CVT (1147 females—66.8%; 810 pyogenic and 908 nonpyogenic CVT, 47.1% and 52.9%, respectively), with 134 patients (7.8%) experiencing a concomitant ICH. The overall incidence rate for CVT was 11.6 per 1 000 000 inhabitants with a sex-specific rate of 15.1 and 7.8 per 1 000 000 in females and males, respectively. CVT incidence significantly increased in women during time of observation (P=0.007), with the highest incidence being at 40 to 44 years (27.0 cases per 1 000 000). In-hospital CFR was 3%, with no difference between pyogenic/nonpyogenic CVT. Patients with concomitant ICH had a higher in-hospital CFR compared with patients without ICH (7.5% versus 2.7%; odds ratio, 2.96 [95% CI, 1.45–6.04]). In-hospital CFR progressively increased with increasing Charlson comorbidity index (P=0.003). Age (odds ratio, 1.03 [95% CI, 1.02–1.05]), Charlson comorbidity index ≥4 (odds ratio, 4.33 [95% CI, 1.29–14.52]), and ICH (odds ratio, 3.05 [95% CI, 1.40–6.62]) were independent predictors of in-hospital mortality.Conclusions:In a large epidemiological study, CVT incidence was found to be comparable to the one registered in population-based studies reported after the year 2000. CVT incidence increased among women over time. In-hospital CFR was low, but not negligible, in patients with concomitant ICH. Age, ICH, and a high number of comorbidities were independent predictors of in-hospital mortality. Pyogenic CVT was not a predictor of in-hospital CFR, although its high proportion was not confirmed by internal validation.
      Citation: Stroke
      PubDate: 2021-08-10T09:00:01Z
      DOI: 10.1161/STROKEAHA.121.034202
       
  • Prevalence, Impact, and Treatment of Co-Occurring Osteoarthritis in
           Patients With Stroke Undergoing Rehabilitation: A Review

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      Authors: John Fournier Hillel Finestone Julia Lauzon T. Mark Campbell Department of Medicine; University of Ottawa, Canada (J.F., H.F., J.L., T.M.C.). Department of Physical Medicine Rehabilitation, Elisabeth Bruyère Hospital, Ottawa, Canada (H.F., T.M.C.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Early, frequent rehabilitation is an important factor for optimizing stroke recovery outcomes. Medical comorbidities, such as osteoarthritis, that affect the ability to participate in rehabilitation could therefore have a detrimental impact on such outcomes. Both stroke and osteoarthritis are becoming more common in developed nations as the population ages. First-line osteoarthritis treatments, such as oral nonsteroidal anti-inflammatory drugs, are often avoided poststroke due to interaction with secondary prevention stroke risk-factor management. Our objective was to summarize the current literature concerning co-occurring osteoarthritis and stroke prevalence, its functional impact, and treatment options.Methods:Narrative review using a comprehensive literature search of PubMed, osteoarthritis, and stroke guidelines. Outcomes related to co-occurrence prevalence, osteoarthritis as a stroke risk-factor, osteoarthritis-related imaging and treatment were extracted and summarized descriptively. Overall quality of the evidence was summarized using Grading of Recommendations Assessment, Development and Evaluation.Results:We identified 23 studies and guidelines related to our objective. Overall quality of the evidence was very low.Conclusions:Few trials have investigated the relationship between osteoarthritis and stroke, nor osteoarthritis-specific pain and function management for stroke survivors. High-quality research evaluating the impact of osteoarthritis on stroke rehabilitation is needed.
      Citation: Stroke
      PubDate: 2021-08-10T09:00:01Z
      DOI: 10.1161/STROKEAHA.121.034270
       
  • Clinical Performance Measures for Stroke Rehabilitation: Performance
           Measures From the American Heart Association/American Stroke Association

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      Authors: Joel Stein Douglas I. Katz Randie M. Black Schaffer Steven C. Cramer Anne F. Deutsch Richard L. Harvey Catherine E. Lang; Kenneth J. Ottenbacher Janet Prvu-Bettger, Elliot J. Roth David L. Tirschwell George F. Wittenberg Steven L. Wolf T. Prashant Nedungadi
      Abstract: Stroke, Ahead of Print.
      The American Heart Association/American Stroke Association released the adult stroke rehabilitation and recovery guidelines in 2016. A working group of stroke rehabilitation experts reviewed these guidelines and identified a subset of recommendations that were deemed suitable for creating performance measures. These 13 performance measures are reported here and contain inclusion and exclusion criteria to allow calculation of rates of compliance in a variety of settings ranging from acute hospital care to postacute care and care in the home and outpatient setting.
      Citation: Stroke
      PubDate: 2021-08-05T09:00:00Z
      DOI: 10.1161/STR.0000000000000388
       
  • Prevalence, Characteristics, and Outcomes of Undetermined Intracerebral
           Hemorrhage: A Systematic Review and Meta-Analysis

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      Authors: Konark Malhotra Christina Zompola Aikaterini Theodorou Aristeidis H. Katsanos Ashkan Shoamanesh Himanshu Gupta Simon Beshara Nitin Goyal Jason Chang Ashis H. Tayal Efstathios Boviatsis Konstantinos Voumvourakis Charlotte Cordonnier David J. Werring Andrei V. Alexandrov Georgios Tsivgoulis Department of Neurology; Allegheny Health Network, Pittsburgh, PA (K.M., A.H.T.). Second Department of Neurology, National Cognition, France (C.C.). Stroke Research Centre, UCL Queen Square Institute of Neurology, London, United Kingdom (D.J.W.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:There are scarce data regarding the prevalence, characteristics and outcomes of intracerebral hemorrhage (ICH) of undetermined (unknown or cryptogenic) etiology. We sought to determine the prevalence, radiological characteristics, and clinical outcomes of undetermined ICH.Methods:Systematic review and meta-analysis of studies involving patients with spontaneous ICH was conducted to primarily assess the prevalence and clinical-radiological characteristics of undetermined ICH. Additionally, we assessed the rates for ICH secondary to hypertensive arteriopathy and cerebral amyloid angiopathy. Subgroup analyses were performed based on the use of (1) etiology-oriented ICH classification, (2) detailed neuroimaging, and (3) Boston criteria among patients with cerebral amyloid angiopathy related ICH. We pooled the prevalence rates using random-effects models, and assessed the heterogeneity using CochranQandI2statistics.Results:We identified 24 studies comprising 15 828 spontaneous ICH patients (mean age, 64.8 years; men, 60.8%). The pooled prevalences of hypertensive arteriopathy ICH, undetermined ICH, and cerebral amyloid angiopathy ICH were 50% (95% CI, 43%–58%), 18% (95% CI, 13%–23%), and 12% (95% CI, 7%–17% [P<0.001 between subgroups]). The volume of ICH was the largest in cerebral amyloid angiopathy ICH (24.7 [95% CI, 19.7–29.8] mL), followed by hypertensive arteriopathy ICH (16.2 [95% CI, 10.9–21.5] mL) and undetermined ICH (15.4 [95% CI, 6.2–24.5] mL). Among patients with undetermined ICH, the rates of short-term mortality (within 3 months) and concomitant intraventricular hemorrhage were 33% (95% CI, 25%–42%) and 38% (95% CI, 28%–48%), respectively. Subgroup analysis demonstrated a higher rate of undetermined ICH among studies that did not use an etiology-oriented classification (22% [95% CI, 15%–29%]). No difference was observed between studies based on the completion of detailed neuroimaging to assess the rates of undetermined ICH (P=0.62).Conclusions:The etiology of spontaneous ICH remains unknown or cryptogenic among 1 in 7 patients in studies using etiology-oriented classification and among 1 in 4 patients in studies that avoid using etiology-oriented classification. The short-term mortality in undetermined ICH is high despite the relatively small ICH volume.
      Citation: Stroke
      PubDate: 2021-08-04T09:00:00Z
      DOI: 10.1161/STROKEAHA.120.031471
       
  • Changes in Stroke Hospital Care During the COVID-19 Pandemic: A Systematic
           Review and Meta-Analysis

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      Authors: Aristeidis H. Katsanos Lina Palaiodimou Ramin Zand Shadi Yaghi Hooman Kamel Babak B. Navi Guillaume Turc Vassiliki Benetou Vijay K. Sharma Dimitris Mavridis Shima Shahjouei Luciana Catanese Ashkan Shoamanesh Konstantinos Vadikolias Konstantinos Tsioufis Pagona Lagiou Petros P. Sfikakis Andrei V. Alexandrov Sotirios Tsiodras Georgios Tsivgoulis Division of Neurology; McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., L.C., A.S.). Second Department of Neurology, “Attikon” Hospital, School of Medicine, National Kapodistrian University of Athens, Greece (S.T.). National Public Health Organization of Greece, Athens (S.T.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:We systematically evaluated the impact of the coronavirus 2019 (COVID-19) pandemic on stroke care across the world.Methods:Observational studies comparing characteristics, acute treatment delivery, or hospitalization outcomes between patients with stroke admitted during the COVID-19 pandemic and those admitted before the pandemic were identified by Medline, Scopus, and Embase databases search. Random-effects meta-analyses were conducted for all outcomes.Results:We identified 46 studies including 129 491 patients. Patients admitted with stroke during the COVID-19 pandemic were found to be younger (mean difference, −1.19 [95% CI, −2.05 to −0.32];I2=70%) and more frequently male (odds ratio, 1.11 [95% CI, 1.01–1.22];I2=54%) compared with patients admitted with stroke in the prepandemic era. Patients admitted with stroke during the COVID-19 pandemic, also, had higher baseline National Institutes of Health Stroke Scale scores (mean difference, 0.55 [95% CI, 0.12–0.98];I2=90%), higher probability for large vessel occlusion presence (odds ratio, 1.63 [95% CI, 1.07–2.48];I2=49%) and higher risk for in-hospital mortality (odds ratio, 1.26 [95% CI, 1.05–1.52];I2=55%). Patients with acute ischemic stroke admitted during the COVID-19 pandemic had higher probability of receiving endovascular thrombectomy treatment (odds ratio, 1.24 [95% CI, 1.05–1.47];I2=40%). No difference in the rates of intravenous thrombolysis administration or difference in time metrics regarding onset to treatment time for intravenous thrombolysis and onset to groin puncture time for endovascular thrombectomy were detected.Conclusions:The present systematic review and meta-analysis indicates an increased prevalence of younger patients, more severe strokes attributed to large vessel occlusion, and higher endovascular treatment rates during the COVID-19 pandemic. Patients admitted with stroke during the COVID-19 pandemic had higher in-hospital mortality. These findings need to be interpreted with caution in view of discrepant reports and heterogeneity being present across studies.
      Citation: Stroke
      PubDate: 2021-08-04T09:00:00Z
      DOI: 10.1161/STROKEAHA.121.034601
       
  • Stroke Hospitalizations Before and During COVID-19 Pandemic Among Medicare
           Beneficiaries in the United States

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      Authors: Quanhe Yang Xin Tong Sallyann Coleman King Benjamin S. Olivari Robert K. Merritt Division for Heart Disease; Prevention, Atlanta, GA. (B.S.O.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Emergency department visits and hospitalizations for stroke declined significantly following declaration of coronavirus disease 2019 (COVID-19) as a national emergency on March 13, 2020, in the United States. This study examined trends in hospitalizations for stroke among Medicare fee-for-service beneficiaries aged ≥65 years and compared characteristics of stroke patients during COVID-19 pandemic to comparable weeks in the preceding year (2019).Methods:For trend analysis, we examined stroke hospitalizations from week 1 in 2019 through week 44 in 2020. For comparison of patient characteristics, we estimated percent reduction in weekly stroke hospitalizations from 2019 to 2020 during weeks 10 through 23 and during weeks 24 through 44 by age, sex, race/ethnicity, and state.Results:Compared to weekly numbers of hospitalizations for stroke reported during 2019, stroke hospitalizations in 2020 decreased sharply during weeks 10 through 15 (March 1–April 11), began increasing during weeks 16 through 23, and remained at a level lower than the same weeks in 2019 from weeks 24 through 44 (June 7–October 31). During weeks 10 through 23, stroke hospitalizations decreased by 22.3% (95% CI, 21.4%–23.1%) in 2020 compared with same period in 2019; during weeks 24 through 44, they decreased by 12.1% (95% CI, 11.2%–12.9%). The magnitude of reduction increased with age but similar between men and women and among different race/ethnicity groups. Reductions in stroke hospitalizations between weeks 10 through 23 varied by state ranging from 0.0% (95% CI, −16.0%–1.7%) in New Hampshire to 36.2% (95% CI, 24.8%–46.7%) in Montana.Conclusions:One-in-5 fewer stroke hospitalizations among Medicare fee-for-service beneficiaries occurred during initial weeks of the COVID-19 pandemic (March 1–June 6) and weekly stroke hospitalizations remained at a lower than expected level from June 7 to October 31 in 2020 compared with 2019. Changes in stroke hospitalizations varied substantially by state.
      Citation: Stroke
      PubDate: 2021-07-29T09:00:01Z
      DOI: 10.1161/STROKEAHA.121.034562
       
  • Greater Adherence to Secondary Prevention Medications Improves Survival
           After Stroke or Transient Ischemic Attack: A Linked Registry Study

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      Authors: Lachlan L. Dalli Joosup Kim Dominique A. Cadilhac Melanie Greenland Frank M. Sanfilippo Nadine E. Andrew Amanda G. Thrift Rohan Grimley Richard I. Lindley Vijaya Sundararajan Douglas E. Crompton Natasha A. Lannin Craig S. Anderson Leanne Whiley Monique F. Kilkenny Stroke; Health, The University of Sydney, NSW, Australia (R.I.L.). Department of Public Health, La Trobe University, Bundoora, VIC, Australia (V.S.). Department of Neurology, Northern Health, Epping, VIC, Australia (D.E.C.). Alfred Health, Melbourne, VIC, Australia (N.A.L.). The George Institute for Global Health, Sydney, NSW, Australia (C.S.A.). The George Institute for Global Health, Peking University Health Science Center, China (C.S.A.). Rockhampton Hospital, QLD, Australia (L.W.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Although a target of 80% medication adherence is commonly cited, it is unclear whether greater adherence improves survival after stroke or transient ischemic attack (TIA). We investigated associations between medication adherence during the first year postdischarge, and mortality up to 3 years, to provide evidence-based targets for medication adherence.Methods:Retrospective cohort study of 1-year survivors of first-ever stroke or TIA, aged ≥18 years, from the Australian Stroke Clinical Registry (July 2010–June 2014) linked with nationwide prescription refill and mortality data (until August 2017). Adherence to antihypertensive agents, statins, and nonaspirin antithrombotic medications was based on the proportion of days covered from discharge until 1 year. Cox regression with restricted cubic splines was used to investigate nonlinear relationships between medication adherence and all-cause mortality (to 3 years postdischarge). Models were adjusted for age, sex, socioeconomic position, stroke factors, primary care factors, and concomitant medication use.Results:Among 8363 one-year survivors of first-ever stroke or TIA (44% aged ≥75 years, 44% female, 18% TIA), 75% were supplied antihypertensive agents. In patients without intracerebral hemorrhage (N=7446), 84% were supplied statins, and 65% were supplied nonaspirin antithrombotic medications. Median adherence was ≈90% for each medication group. Between 1% and 100% adherence, greater adherence to statins or antihypertensive agents, but not nonaspirin antithrombotic agents, was associated with improved survival. When restricted to linear regions above 60% adherence, each 10% increase in adherence was associated with a reduction in all-cause mortality of 13% for antihypertensive agents (hazard ratio, 0.87 [95% CI, 0.81–0.95]), 13% for statins (hazard ratio, 0.87 [95% CI, 0.80–0.95]), and 15% for nonaspirin antithrombotic agents (hazard ratio, 0.85 [95% CI, 0.79–0.93]).Conclusions:Greater levels of medication adherence after stroke or TIA are associated with improved survival, even among patients with near-perfect adherence. Interventions to improve medication adherence are needed to maximize survival poststroke.
      Citation: Stroke
      PubDate: 2021-07-28T09:00:01Z
      DOI: 10.1161/STROKEAHA.120.033133
       
  • Oral Anticoagulants in Atrial Fibrillation Patients With Recent Stroke Who
           Are Dependent on the Daily Help of Others

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      Authors: Louisa Meya Alexandros A. Polymeris Sabine Schaedelin Fabian Schaub Valerian L. Altersberger Christopher Traenka Sebastian Thilemann Benjamin Wagner Joachim Fladt Lisa Hert Sohei Yoshimura Masatoshi Koga Annaelle Zietz Tolga Dittrich Urs Fisch Kazunori Toyoda David J. Seiffge Nils Peters Gian Marco De Marchis Henrik Gensicke Leo H. Bonati Philippe A. Lyrer Stefan T. Engelter Department of Neurology; Stroke Center, Hirslanden Hospital, Zurich, Switzerland (N.P.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Data on the effectiveness and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in patients with stroke attributable to atrial fibrillation (AF) who were dependent on the daily help of others at hospital discharge are scarce.Methods:Based on prospectively obtained data from the observational Novel-Oral-Anticoagulants-in-Ischemic-Stroke-Patients-longterm registry from Basel, Switzerland, we compared the occurrence of the primary outcome—the composite of recurrent ischemic stroke, major bleeding, and all-cause death—among consecutive patients with AF-stroke treated with either VKAs or DOACs between patients dependent (defined as modified Rankin Scale score, 3–5) and patients independent at discharge. We used simple, adjusted, and weighted Cox proportional hazards regression to account for potential confounders.Results:We analyzed 801 patients (median age 80 years, 46% female), of whom 391 (49%) were dependent at discharge and 680 (85%) received DOACs. Over a total follow-up of 1216 patient-years, DOAC- compared to VKA-treated patients had a lower hazard for the composite outcome (hazard ratio [HR], 0.58 [95% CI, 0.42–0.81]), as did independent compared to dependent patients (HR, 0.54 [95% CI, 0.40–0.71]). There was no evidence that the effect of anticoagulant type (DOAC versus VKA) on the hazard for the composite outcome differed between dependent (HRdependent, 0.68 [95% CI, 0.45–1.01]) and independent patients (HRindependent, 0.44 [95% CI, 0.26–0.75]) in the simple model (Pinteraction=0.212). Adjusted (HRdependent, 0.74 [95% CI, 0.49–1.11] and HRindependent, 0.51 [95% CI, 0.30–0.87];Pinteraction=0.284) and weighted models (HRdependent, 0.79 [95% CI, 0.48–1.31] and HRindependent, 0.46 [95% CI, 0.26–0.81];Pinteraction=0.163) yielded concordant results. Secondary analyses focusing on the individual components of the composite outcome were consistent to the primary analyses.Conclusions:The benefits of DOACs in patients with atrial fibrillation with a recent stroke were maintained among patients who were dependent on the help of others at discharge.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT03826927.
      Citation: Stroke
      PubDate: 2021-07-27T09:00:01Z
      DOI: 10.1161/STROKEAHA.120.033862
       
  • Middle Cerebral Artery M2 Thrombectomy in the STRATIS Registry

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      Authors: Mouhammad A. Jumaa Alicia C. Castonguay Hisham Salahuddin Ashutosh P. Jadhav Kaustubh Limaye Mudassir Farooqui Syed F. Zaidi Nils Mueller-Kronast David S. Liebeskind Osama O. Zaidat Santiago Ortega-Gutierrez Department of Neurology, University of Toledo, OH (M.A.J; A.C.C, H.S, S.F.Z.). ProMedica Toledo Hospital, OH (M.A.J, S.F.Z.). Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (A.P.J.). University of Iowa, Iowa City (K.L, M.F, S.O.-G.). Advanced Neuroscience Network, Tenet, South Florida (N.M.-K.). Department of Neurology, University of California Los Angeles (D.S.L.). St. Vincent Mercy Hospital, Toledo, OH (O.O.Z.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The safety and benefit of mechanical thrombectomy in the treatment of acute ischemic stroke patients with M2 segment middle cerebral artery occlusions remain uncertain. Here, we compare clinical and angiographic outcomes in M2 versus M1 occlusions in the STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) Registry.Methods:The STRATIS Registry was a prospective, multicenter, nonrandomized, observational study of acute ischemic stroke large vessel occlusion patients treated with the Solitaire stent-retriever as the first-choice therapy within 8 hours from symptoms onset. Primary outcome was defined as functional disability at 3 months measured by dichotomized modified Rankin Scale. Secondary outcomes included reperfusion rates and rates of symptomatic intracranial hemorrhage.Results:A total of 984 patients were included, of which 538 (54.7%) had M1 and 170 (17.3%) had M2 occlusions. Baseline demographics were well balanced within the groups, with the exception of mean baseline National Institutes of Health Stroke Scale score which was significantly higher in the M1 population (17.3±5.5 versus 15.7±5.0,P≤0.001). No difference was seen in mean puncture to revascularization times between the cohorts (46.0±27.8 versus 45.1±29.5 minutes,P=0.75). Rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction≥2b) were similar between the groups (91% versus 95%,P=0.09). M2 patients had significantly increased rates of symptomatic ICH at 24 hours (4% versus 1%,P=0.01). Rates of good functional outcome (modified Rankin Scale score of 0–2; 58% versus 59%,P=0.83) and mortality (15% versus 14%,P=0.75) were similar between the 2 groups. There was no difference in the association of outcome and onset to groin puncture or onset to successful reperfusion in M1 and M2 occlusions.Conclusions:In the STRATIS Registry, M2 occlusions achieved similar rates of successful reperfusion, good functional outcome, and mortality, although increased rates of symptomatic ICH were demonstrated when compared with M1 occlusions. The time dependence of benefit was also similar between the 2 groups. Further studies are needed to understand the benefit of mechanical thrombectomy for M2 occlusions.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT02239640.
      Citation: Stroke
      PubDate: 2021-07-27T09:00:01Z
      DOI: 10.1161/STROKEAHA.120.033951
       
  • Deep Cerebral Perforators: Anatomical Distribution and Clinical Symptoms:
           An Overview

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      Authors: Valerie Vogels Ruben Dammers Martine van Bilsen Victor Volovici Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC Rotterdam, the Netherlands (V.Vogels, R.D; V.Volovici). Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands (M.v.B.).
      Abstract: Stroke, Ahead of Print.
      The anatomic distribution of the deep cerebral perforators is considered either a given or subject to enormous variability. Most published overviews on this topic only report findings from a limited number of anatomic dissections, and no attempt has been made to date to provide a comprehensive overview of all published data. A comprehensive literature search was performed on MEDLINE, Embase, and Google Scholar with the help of an information specialist. Three types of studies were included: (1) articles that described the anatomy and distribution territories of perforator groups arising from the arteries of the circle of Willis; (2) studies that evaluated the anatomy of the deep cerebral perforators using imaging techniques; and (3) studies that evaluated either microsurgically or radiologically confirmed perforator occlusion and reported the (magnetic resonance imaging–confirmed) distribution territory of the infarction together with a description of the clinical symptoms associated as a result of the infarction. A total of 2715 articles were screened and 53 were included. Of these, 40 dealt with the anatomic and imaging anatomy of perforator groups (37 reported results of dissections and 3 results of imaging studies), with a total of 2421 hemispheres investigated. Another 13 articles with 680 patients were included that evaluated perforator infarction territories. The deep cerebral perforator distribution shows large variability with poor concordance rates among reported studies, with the exception of the posterior communicating and anterior choroidal artery perforators. Despite the assumption that cerebral perforator anatomy is a given, studies show large variability in the anatomic distribution of various perforator groups. Perforator anatomy and relationships between perforator groups, as well as potential collateral circulation in these territories should be prioritized as a research topic in cerebrovascular disease in the near future.
      Citation: Stroke
      PubDate: 2021-07-27T09:00:01Z
      DOI: 10.1161/STROKEAHA.120.034096
       
  • Invasive Multimodal Neuromonitoring in Aneurysmal Subarachnoid Hemorrhage:
           A Systematic Review

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      Authors: Michael Veldeman Walid Albanna Miriam Weiss Soojin Park Anke Hoellig Hans Clusmann Raimund Helbok Yasin Temel Gerrit Alexander Schubert Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany (M.A; W.A, M.W, A.H, H.C, G.A.S.). Department of Neurology, Columbia University Irving Medical Center, NY (S.P.). Department of Neurology, Medical University of Innsbruck, Austria (R.H.). Department of Neurosurgery, Maastricht University Medical Centre, the Netherlands (Y.T). Department of Neurosurgery, Kantonsspital Aarau, Switzerland (G.A.S.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Aneurysmal subarachnoid hemorrhage is a devastating disease leaving surviving patients often severely disabled. Delayed cerebral ischemia (DCI) has been identified as one of the main contributors to poor clinical outcome after subarachnoid hemorrhage. The objective of this review is to summarize existing clinical evidence assessing the diagnostic value of invasive neuromonitoring (INM) in detecting DCI and provide an update of evidence since the 2014 consensus statement on multimodality monitoring in neurocritical care.Methods:Three invasive monitoring techniques were targeted in the data collection process: brain tissue oxygen tension (ptiO2), cerebral microdialysis, and electrocorticography. Prospective and retrospective studies as well as case series (≥10 patients) were included as long as monitoring was used to detect DCI or guide DCI treatment.Results:Forty-seven studies reporting INM in the context of DCI were included (ptiO2: N=21; cerebral microdialysis: N=22; electrocorticography: N=4). Changes in brain oxygen tension are associated with angiographic vasospasm or reduction in regional cerebral blood flow. Metabolic monitoring with trend analysis of the lactate to pyruvate ratio using cerebral microdialysis, identifies patients at risk for DCI. Clusters of cortical spreading depolarizations are associated with clinical neurological worsening and cerebral infarction in selected patients receiving electrocorticography monitoring.Conclusions:Data supports the use of INM for the detection of DCI in selected patients. Generalizability to all subarachnoid hemorrhage patients is limited by design bias of available studies and lack of randomized trials. Continuous data recording with trend analysis and the combination of INM modalities can provide tailored treatment support in patients at high risk for DCI. Future trials should test interventions triggered by INM in relation to cerebral infarctions.
      Citation: Stroke
      PubDate: 2021-07-26T09:00:00Z
      DOI: 10.1161/STROKEAHA.121.034633
       
  • FIP1L1-PDGFRA-Associated Hypereosinophilic Syndrome as a Treatable Cause
           of Watershed Infarction

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      Authors: Juliette Tennenbaum Matthieu Groh Laura Venditti France Campos-Gazeau Emilie Chalayer Thomas De Broucker Mohamed Hamidou Mathilde Hunault Aicha Lyoubi Raphaëlle Meunier Thierry Muron Damien Sène Borhane Slama Céline Guidoux Guillaume Lefèvre Jean-Emmanuel Kahn Christian Denier Julien Rohmer National Reference Center for Hypereosinophilic syndromes (CEREO); France (J.T., M.G., M. Hamidou, G.L., J.-E.K., J.R.). Department of Neurology, CHU du Kremlin-Bicêtre, France (J.T., L.V., C.D.). Department of Internal Medicine, Hôpital Foch, Suresnes, France (M.G., J.R.). Department of Hematology, Hôpital d’Haguenau, France (F.C.-G.). Department of Hematology Cell Therapy, Saint-Priest-en-Jarez, France. (E.C.) Department of Oncology, Saint-Priest-en-Jarez, France. (T.M.) Department of Neurology, Hôpital Delafontaire, Saint Denis, France (T.D.B., A.L.). Department of Internal Medicine, CHU de Nantes, France (M. Hamidou). CRCINA CHU d’Angers, France (M. Hunault). Department of Rheumatology, Hôpital de Libourne, France (R.M.). Department of Internal Medicine, CHU Lariboisière, Paris, France (D.S.). Department of Hematology, Hôpital d’Avignon, France (B.S.). Department of Neurology, CHU Bichat, Paris, France (C.G.). Department of Internal Medicine, CHU Lille, France (G.L.). Department of Internal Medicine, CHU Ambroise Paré, Boulogne-Billancourt, France (J.-E.K.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Ischemic stroke has been reported in various conditions associated with eosinophilia.FIP1L1-PDGFRAfusion ([Fip1-like 1-platelet-derived growth factor receptor alpha];F/P) leads to the proliferation of the eosinophilic lineage and thus to a clonal hypereosinophilic syndrome that is highly responsive to imatinib.Methods:We previously reported on a nationwide retrospective study of 151 patients withF/P-associated clonal hypereosinophilic syndrome. Patients from this cohort with a clinical history of ischemic stroke (as well as 2 additional cases) were further analyzed to better define their clinical picture and outcomes.Results:Sixteen male patients (median age, 51 [43–59] years) with low-to-intermediate cardiovascular risk were included. Median National Institutes of Health Stroke Scale was 4 (range, 1–6). Most cerebral imaging disclosed multiple bilateral infarctions of watershed distribution (69%). Despite frequent cardiac involvement (50%), cardiac thrombus was evidenced in a single patient and, according to the TOAST classification (Trial of ORG 10172 in Acute Stroke Treatment), 62.5% of strokes were presumably of undetermined etiology. Among the 15 patients treated with imatinib, and after a median follow-up of 4.5 years, stroke recurred in only 3 patients (consisting of either cardio embolic or hemorrhagic events, unrelated to the first episode).Conclusions:F/P+ clonal hypereosinophilic syndrome is a diagnosis to consider in patients with unexplained ischemic stroke and hypereosinophilia (especially in the setting of multiple cortical borderzone distribution) and warrants prompt initiation of imatinib.
      Citation: Stroke
      PubDate: 2021-07-26T09:00:00Z
      DOI: 10.1161/STROKEAHA.121.034191
       
  • Posttreatment Ischemic Lesion Evolution Is Associated With Reduced
           Favorable Functional Outcome in Patients With Stroke

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      Authors: Praneeta Konduri Henk van Voorst Amber Bucker Katinka van Kranendonk Anna Boers Kilian Treurniet Olvert Berkhemer Albert J. Yoo Wim van Zwam Robert van Oostenbrugge Aad van der Lugt Diederik Dippel Yvo Roos Joost Bot Charles Majoie Henk Marquering Department of Biomedical Engineering; Nuclear Medicine, Amsterdam UMC, Vrije Universiteit van Amsterdam (J.B.). , on behalf of the MR CLEAN Trial Investigators* Puck S.S. Fransen Debbie Beumer Lucie A. van den Berg Hester F. Lingsma Wouter J. Schonewille Jan Albert Vos Paul J. Nederkoorn Marieke J.H. Wermer Marianne A.A. van Walderveen Julie Staals Jeannette Hofmeijer Jacques A. van Oostayen Geert J. Lycklama à Nijeholt Jelis Boiten Patrick A. Brouwer Bart J. Emmer Sebastiaan F. de Bruijn Lukas C. van Dijk L. Jaap Kappelle Rob H. Lo Ewoud J. van Dijk Joost de Vries Paul L.M. de Kort Willem Jan J. van Rooij Jan S.P. van den Berg A.A.M. van Hasselt Isala Klinieken Leo A.M. Aerden René J. Dallinga Reinier de Graaf Gasthuis Marieke C. Visser Joseph C.J. Bot Patrick C. Vroomen Omid Eshghi Tobien H.C.M.L. Schreuder Roel J.J. Heijboer Koos Keizer Alexander V. Tielbeek Heleen M. den Hertog Dick G. Gerrits Renske M. van den Berg-Vos Giorgos B. Karas Ewout W. Steyerberg H. Zwenneke Flach Isala Klinieken Marieke E.S. Sprengers Sjoerd F.M. Jenniskens Ludo F.M. Beenen René van den Berg Peter J. Koudstaal
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Ischemic lesion volume can increase even 24 hours after onset of an acute ischemic stroke. In this study, we investigated the association of lesion evolution with functional outcome and the influence of successful recanalization on this association.Methods:We included patients from the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) who received good quality noncontrast CT images 24 hours and 1 week after stroke onset. The ischemic lesion delineations included infarct, edema, and hemorrhagic transformation. Lesion evolution was defined as the difference between the volumes measured on the 1-week and 24-hour noncontrast CTs. The association of lesion evolution with functional outcome was evaluated using unadjusted and adjusted logistic regression. Adjustments were made for baseline, clinical, and imaging parameters that were associatedP<0.10) in univariate analysis with favorable functional outcome, defined as modified Rankin Scale score of ≤2. Interaction analysis was performed to evaluate the influence of successful recanalization, defined as modified Arterial Occlusion Lesion score of 3 points, on this association.Results:Of the 226 patients who were included, 69 (31%) patients achieved the favorable functional outcome. Median lesion evolution was 22 (interquartile range, 10–45) mL. Lesion evolution was significantly inversely correlated with favourable functional outcome: unadjusted odds ratio, 0.76 (95% CI, 0.66–0.86; per 10 mL of lesion evolution;P<0.01) and adjusted odds ratio: 0.85 (95% CI, 0.72–0.97; per 10 mL of lesion evolution;P=0.03). There was no significant interaction of successful recanalization on the association of lesion evolution and favorable functional outcome (odds ratio, 1.01 [95% CI, 0.77–1.36];P=0.94).Conclusions:In our population, subacute ischemic lesion evolution is associated with unfavorable functional outcome. This study suggests that even 24 hours after onset of stroke, deterioration of the brain continues, which has a negative effect on functional outcome. This finding may warrant additional treatment in the subacute phase.
      Citation: Stroke
      PubDate: 2021-07-22T09:00:00Z
      DOI: 10.1161/STROKEAHA.120.032331
       
  • Obesity and Risk for First Ischemic Stroke Depends on Metabolic Syndrome:
           The HUNT Study

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      Authors: Jens W. Horn Tingting Feng Bjørn Mørkedal Linn Beate Strand Julie Horn Kenneth Mukamal Imre Janszky Department of Internal Medicine; Levanger Hospital, Health Trust Nord-Trøndelag, Norway (J.W.H.). Department of Public Health Gynecology, Levanger Hospital, Nord-Trøndelag Hospital Trust, Norway (J.H.). Department of Medicine, Beth Israel Deaconess Medical Center, Boston (K.M.). Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden (I.J.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Obesity is one of the most prevalent modifiable risk factors of ischemic stroke. However, it is still unclear whether obesity itself or the metabolic abnormalities due to obesity increase the risk of ischemic stroke. We therefore investigated the association between metabolic health, weight, and risk of ischemic stroke in a large prospective cohort study.Methods:In the Norwegian HUNT study (Trøndelag Health Study), we included 35 105 participants with complete information on metabolic risk factors and relevant covariates. Metabolically unhealthy state was defined as sex specific increased waist circumference in addition to 2 or more of the following criteria: hypertension, increased blood pressure, decreased high-density lipoprotein, triglycerides or glucose, or self-reported diagnosis of diabetes. We then applied Cox proportional hazard models to estimate the risk for ischemic stroke among overweight and obese metabolically healthy and unhealthy participants compared with metabolically healthy, normal weight participants.Results:A total of 1161 ischemic stroke cases occurred after an average observation time of 11.9 years. In general, metabolically unhealthy participants were at increased risk of ischemic stroke (for obese participants: hazard ratio, 1.30 [95% CI, 1.09–1.56] compared with metabolically healthy participants with a normal body mass index). Hypertension appeared to be the most important metabolic risk factor. Metabolically healthy participants with overweight or obesity were at similar risk of ischemic stroke compared with normal weight participants (hazard ratio, 1.02 [95% CI, 0.81–1.28] for participants with obesity). Obesity and overweight even over an extended period of time seems to be benign about ischemic stroke, as long as it was not associated with metabolic abnormalities.Conclusions:Obesity was not an independent ischemic stroke risk factor in this cohort, and the risk depended more on the metabolic consequences of obesity.
      Citation: Stroke
      PubDate: 2021-07-20T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033016
       
  • Endovascular Treatment Effect Diminishes With Increasing Thrombus
           Perviousness

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      Authors: Manon Kappelhof Manon L. Tolhuisen Kilian M. Treurniet Bruna G. Dutra Heitor Alves Guang Zhang Scott Brown Keith W. Muir Antoni Dávalos Yvo B.W.E.M. Roos Jeffrey L. Saver Andrew M. Demchuk Tudor G. Jovin Serge Bracard Bruce C.V. Campbell Aad van der Lugt Francis Guillemin Philip White Michael D. Hill Diederik W.J. Dippel Peter J. Mitchell Mayank Goyal Henk A. Marquering Charles B.L.M. Majoie Radiology; Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands. (A.v.d.L.) Neurology, Erasmus Medical Center, Rotterdam, the Netherlands. (D.W.J.D.) Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Thrombus perviousness estimates residual flow along a thrombus in acute ischemic stroke, based on radiological images, and may influence the benefit of endovascular treatment for acute ischemic stroke. We aimed to investigate potential endovascular treatment (EVT) effect modification by thrombus perviousness.Methods:We included 443 patients with thin-slice imaging available, out of 1766 patients from the pooled HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials) data set of 7 randomized trials on EVT in the early window (most within 8 hours). Control arm patients (n=233) received intravenous alteplase if eligible (212/233; 91%). Intervention arm patients (n=210) received additional EVT (prior alteplase in 178/210; 85%). Perviousness was quantified by thrombus attenuation increase on admission computed tomography angiography compared with noncontrast computed tomography. Multivariable regression analyses were performed including multiplicative interaction terms between thrombus attenuation increase and treatment allocation. In case of significant interaction, subgroup analyses by treatment arm were performed. Our primary outcome was 90-day functional outcome (modified Rankin Scale score), resulting in an adjusted common odds ratio for a one-step shift towards improved outcome. Secondary outcomes were mortality, successful reperfusion (extended Thrombolysis in Cerebral Infarction score, 2B–3), and follow-up infarct volume (in mL).Results:Increased perviousness was associated with improved functional outcome. After adding a multiplicative term of thrombus attenuation increase and treatment allocation, model fit improved significantly (P=0.03), indicating interaction between perviousness and EVT benefit. Control arm patients showed significantly better outcomes with increased perviousness (adjusted common odds ratio, 1.2 [95% CI, 1.1–1.3]). In the EVT arm, no significant association was found (adjusted common odds ratio, 1.0 [95% CI, 0.9–1.1]), and perviousness was not significantly associated with successful reperfusion. Follow-up infarct volume (12% [95% CI, 7.0–17] per 5 Hounsfield units) and chance of mortality (adjusted odds ratio, 0.83 [95% CI, 0.70–0.97]) decreased with higher thrombus attenuation increase in the overall population, without significant treatment interaction.Conclusions:Our study suggests that the benefit of best medical care including alteplase, compared with additional EVT, increases in patients with more pervious thrombi.
      Citation: Stroke
      PubDate: 2021-07-20T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033124
       
  • Association of Chronic Liver Disease and Mortality in Patients With
           Aneurysmal Subarachnoid Hemorrhage

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      Authors: Yu Zhang Linjie Li Lu Jia Weelic Chong Yang Hai L. Dade Lunsford Chao You Yongzhong Cheng Fang Fang Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China (Y.Z; L.L, L.J, C.Y, Y.C, F.F.). Thomas Jefferson University, Philadelphia, PA (W.C, Y.H.). Department of Neurosurgery, University of Pittsburgh Medical Center, PA (L.D.L.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Chronic liver disease (CLD) is a risk factor for increased morbidity and mortality in acutely ill patients. For patients with aneurysmal subarachnoid hemorrhage (aSAH), the association between CLD and mortality remains unknown.Methods:In this retrospective cohort study, we analyzed consecutive aSAH patients admitted to the West China Hospital between 2009 and 2019. The primary outcome was in-hospital all-cause mortality.Results:This study included 6228 cases of aSAH, 489 (7.9%) of whom also had CLD. In a propensity-matched analysis, CLD was associated with increased mortality in patients with aSAH compared with non-CLD (odds ratio, 2.04 [95% CI, 1.43–2.92]). In aSAH patients with CLD, a high Model for End-Stage Liver Disease score was still associated with an increased odds of mortality.Conclusions:Among aSAH patients, CLD was associated with increased mortality compared with non-CLD. Among aSAH patients with CLD, a higher Model for End-Stage Liver Disease score was associated with an increased odds of mortality.
      Citation: Stroke
      PubDate: 2021-07-20T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034136
       
  • Innate Immune Anti-Inflammatory Response in Human Spontaneous
           Intracerebral Hemorrhage

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      Authors: Anan Shtaya Leslie R. Bridges Rebecca Williams Sarah Trippier Liqun Zhang Anthony C. Pereira James A.R. Nicoll Delphine Boche Atticus H. Hainsworth Molecular; Experimental Sciences, Faculty of Medicine, University of Southampton, United Kingdom (J.A.R.N., D.B.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Spontaneous intracerebral hemorrhage (sICH) is a common form of hemorrhagic stroke, with high mortality and morbidity. Pathophysiological mechanisms in sICH are poorly understood and treatments limited. Neuroinflammation driven by microglial-macrophage activation contributes to brain damage post-sICH. We aim to test the hypothesis that an anti-inflammatory (repair) process occurs in parallel with neuroinflammation in clinical sICH.Methods:We performed quantitative analysis of immunohistochemical markers for microglia and macrophages (Iba1, CD68, TMEM119, CD163, and CD206) in brain tissue biospecimens 1 to 12 days post-sICH and matched control cases. In a parallel, prospective group of patients, we assayed circulating inflammatory markers (CRP [C-reactive protein], total white cell, and monocyte count) over 1 to 12 days following sICH.Results:In 27 supratentorial sICH cases (n=27, median [interquartile range] age: 59 [52–80.5], 14F/13M) all microglia-macrophage markers increased post-sICH, relative to control brains. Anti-inflammatory markers (CD163 and CD206) were elevated alongside proinflammatory markers (CD68 and TMEM119). CD163 increased progressively post-sICH (15.0-fold increase at 7–12 days,P<0.001). CD206 increased at 3 to 5 days (5.2-fold,P<0.001) then returned to control levels at 7 to 12 days. The parenchymal immune response combined brain-derived microglia (TMEM119 positive) and invading monocyte-derived macrophages (CD206 positive). In a prospective sICH patient cohort (n=26, age 74 [66–79], National Institutes of Health Stroke Scale on admission: 8 [4–17]; 14F/12M) blood CRP concentration and monocyte density (but not white blood cell) increased post-sICH. CRP increased from 0 to 2 to 3 to 5 days (8.3-fold,P=0.020) then declined at 7 to 12 days. Monocytes increased from 0 to 2 to 3 to 5 days (1.8-fold,P<0.001) then declined at 7 to 12 days.Conclusions:An anti-inflammatory pathway, enlisting native microglia and blood monocytes, occurs alongside neuroinflammation post-sICH. This novel pathway offers therapeutic targets and a window of opportunity (3–5 days post-sICH) for delivery of therapeutics via invading monocytes.
      Citation: Stroke
      PubDate: 2021-07-20T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034673
       
  • Core Outcome Measures for Palliative and End-of-Life Research After Severe
           Stroke: Mixed-Method Delphi Study

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      Authors: Bruce Mason Kirsty Boyd Fergus Doubal Mark Barber Marian Brady Eileen Cowey Akila Visvanathan Steff Lewis Katie Gallacher Sarah Morton Gillian E. Mead Usher Institute (B.M.; K.B., S.L., S.M, G.E.M) Centre for Clinical Brain Sciences (F.D). University of Edinburgh, University Hospital, Monklands, NHS Lanarkshire (M. Barber). Midwifery University of Edinburgh (A.V.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Stroke is the second commonest cause of death worldwide and a leading cause of severe disability, yet there are no published trials of palliative care in stroke. To design and evaluate palliative care interventions for people with stroke, researchers need to know what measurable outcomes matter most to patients and families, stroke professionals, and other service providers.Methods:A multidisciplinary steering group of professionals and laypeople managed the study. We synthesized recommendations from respected United Kingdom and international consensus documents to generate a list of outcome domains and then performed a rapid scoping literature review to identify potential outcome measures for use in future trials of palliative care after stroke. We then completed a 3-round, online Delphi survey of professionals, and service users to build consensus about outcome domains and outcome measures. Finally, we held a stakeholder workshop to review and finalize this consensus.Results:We generated a list of 36 different outcome domains from 4 key policy documents. The rapid scoping review identified 43 potential outcome measures that were used to create a shortlist of 16 measures. The 36 outcome domains and 16 measures were presented to a Delphi panel of diverse healthcare professionals and lay service users. Of 48 panelists invited to take part, 28 completed all 3 rounds. Shared decision-making and quality of life were selected as the most important outcome domains for future trials of palliative care in stroke. Additional comments highlighted the need for outcomes to be feasible, measurable, and relevant beyond the initial, acute phase of stroke. The stakeholder workshop endorsed these results.Conclusions:Future trials of palliative care after stroke should include pragmatic outcome measures, applicable to the evolving patient and family experiences after stroke and be inclusive of shared decision-making and quality of life.
      Citation: Stroke
      PubDate: 2021-07-16T09:00:01Z
      DOI: 10.1161/STROKEAHA.120.032650
       
  • Optic Tract Shrinkage Limits Visual Restoration After Occipital Stroke

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      Authors: Berkeley K. Fahrenthold Matthew R. Cavanaugh Subin Jang Allison J. Murphy Sara Ajina Holly Bridge Krystel R. Huxlin Flaum Eye Institute; University of Rochester, NY. Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom. Department of Neurorehabilitation Neurosurgery, Queen Square, London, United Kingdom. (A.J.M.)
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Damage to the adult primary visual cortex (V1) causes vision loss in the contralateral visual hemifield, initiating a process of trans-synaptic retrograde degeneration. The present study examined functional implications of this process, asking if degeneration impacted the amount of visual recovery attainable from visual restoration training in chronic patients, and if restoration training impacted optic tract (OT) shrinkage.Methods:Magnetic resonance imaging was used to measure OT volumes bilaterally in 36 patients with unilateral occipital stroke. From OT volumes, we computed laterality indices (LI), estimating the stroke-induced OT shrinkage in each case. A subset of these chronic patients (n=14, 13±6 months poststroke) underwent an average of nearly 1 year of daily visual restoration training, which repeatedly stimulated vision in their blind field. The amount of visual field recovery was quantified using Humphrey perimetry, and post training magnetic resonance imaging was used to assess the impact of training on OT shrinkage.Results:OT LI was correlated with time since stroke: it was close to 0 (no measurable OT shrinkage) in subacute participants (<6 months poststroke) while chronic participants (>6 months poststroke) exhibited LI >0, but with significant variability. Visual training did not systematically alter LI, but chronic patients with baseline LI≈0 (no OT shrinkage) exhibited greater visual field recovery than those with LI>0.Conclusions:Unilateral OT shrinkage becomes detectable with magnetic resonance imaging by ≈7 months poststroke, albeit with significant interindividual variability. Although visual restoration training did not alter the amount of degeneration already sustained, OT shrinkage appeared to serve as a biomarker of the potential for training-induced visual recovery in chronic cortically blind patients.
      Citation: Stroke
      PubDate: 2021-07-16T09:00:01Z
      DOI: 10.1161/STROKEAHA.121.034738
       
  • INSTRuCT: Protocol, Infrastructure, and Governance

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      Authors: Jeyaraj Durai Pandian Shweta Jain Verma Deepti Arora Meenakshi Sharma Rupinder Dhaliwal Himani Khatter Rahul Huilgol P.N. Sylaja Aneesh Dhasan Vishnu Renjith Abhishek Pathak Aparna Pai Arvind Sharma Anand Vaishnav Biman Ray Dheeraj Khurana Gaurav Mittal Girish Kulkarni Ivy Sebastian Jayanta Roy Somasundaram Kumaravelu Lydia John Mahesh Kate M.V. Srivastava Madhusudhan Byadarahalli Kempegowda Nomal Borah Neetu Ramrakhiani Nirendra Rai Pawan Ojha Rohit Bhatia Rupjyoti Das Sachin Sureshbabu Shaikh Afshan Jabeen Sanjeev Bhoi Sanjith Aaron Prabhakaran Sarma Aralikatte Onkarappa Saroja Sherly Abraham Sudhir Sharma Sulena Sulena Sankar Gorthi Sundarachary Nagarjunakonda Sunil Narayan Thomas Mathew Tina George Pamidimukkala Vijaya Vikram Huded Vivek Nambiar Y. Muralidhar Reddy Department of Neurology; Christian Medical College, Ludhiana, Punjab, India. (J.D.P., S.J.V., D.A., H.K., R.H., M.K.) Non-Communicable Diseases Section, Indian Council of Medical Research, New Delhi, India (M.S., R. Dhaliwal). Department of Neurology, Sri Chitra Tirunal Institute of Medical Sciences Research, Puducherry, India (S. Narayan). Department of Neurology, St John’s Medical College, Bangalore, Karnataka, India (T.M.). Department of Neurology, Lalitha Super Speciality Hospital, Guntur, Andhra Pradesh, India (P.V.). Department of Neurology, Mazumdar Shaw Medical Centre, Narayana Hrudayalaya, Bangalore, Karnataka, India (V.H.). Department of Neurology, Amrita Institute of Medical Sciences, Kochi, Kerala, India (V.N.). Department of Neurology, CARE Hospital, Hyderabad, Telangana, India (M.R.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Very few large scale multicentric stroke clinical trials have been done in India. The Indian Council of Medical Research funded INSTRuCT (Indian Stroke Clinical Trial Network) as a task force project with the objectives to establish a state-of-the-art stroke clinical trial network and to conduct pharmacological and nonpharmacological stroke clinical trials relevant to the nation and globally. The purpose of the article is to enumerate the structure of multicentric stroke network, with emphasis on its scope, challenges and expectations in India.Methods:Multiple expert group meetings were conducted by Indian Council of Medical Research to understand the scope of network to perform stroke clinical trials in the country. Established stroke centers with annual volume of 200 patients with stroke with prior experience of conducting clinical trials were included. Central coordinating center, standard operating procedures, data and safety monitoring board were formed.Discussion:In first phase, 2 trials were initiated namely, SPRINT (Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India) and Ayurveda treatment in the rehabilitation of patients with ischemic stroke in India (RESTORE [Rehabilitation of Ischemic stroke Patients in India: A Randomized controlled trial]). In second phase, 4 trials have been approved. SPRINT trial was the first to be initiated. SPRINT trial randomized first patient on April 28, 2018; recruited 3048 patients with an average of 128.5 per month so far. The first follow-up was completed on May 27, 2019. RESTORE trial randomized first patient on May 22, 2019; recruited 49 patients with an average of 3.7 per month so far. The first follow-up was completed on August 30, 2019.Conclusions:In next 5 years, INSTRuCT will be able to complete high-quality large scale stroke trials which are relevant globally.REGISTRATION:URL:http://www.ctri.nic.in/; Unique Identifier: CTRI/2017/05/008507.
      Citation: Stroke
      PubDate: 2021-06-25T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033149
       
  • Clinical Effectiveness of the Queen Square Intensive Comprehensive Aphasia
           Service for Patients With Poststroke Aphasia

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      Authors: Alexander P. Leff Sarah Nightingale Beth Gooding Jean Rutter Nicola Craven Makena Peart Alice Dunstan Amy Sherman Andrew Paget Morvwen Duncan Jonathan Davidson Naveen Kumar Claire Farrington-Douglas Camille Julien Jennifer T. Crinion UCL Queen Square Institute of Neurology, University College London, United Kingdom. (A.P.L; S.N.) Institute of Cognitive Neuroscience, University College London, United Kingdom. (J.T.C.) University College London Hospitals NHS Trust, United Kingdom (A.P.L, B.G, A.S, A.P, J.D, N.K, C.J.). Linguistic Resolutions, United Kingdom (J.R, C.F.-D.). Royal London Hospital, Barts Health NHS Trust, United Kingdom (N.C.). City, University of London, United Kingdom (M.P.). Homerton University Hospital NHS Foundation Trust, United Kingdom (A.D.). Great Ormond Street Hospital for Children NHS Foundation Trust, United Kingdom (M.D.).
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Poststroke aphasia has a major impact on peoples’ quality of life. Speech and language therapy interventions work, especially in high doses, but these doses are rarely achieved outside of research studies. Intensive Comprehensive Aphasia Programs (ICAPs) are an option to deliver high doses of therapy to people with aphasia over a short period of time.Methods:Forty-six people with aphasia in the chronic stage poststroke completed the ICAP over a 3-week period, attending for 15 days and averaging 6 hours of therapy per day. Outcome measures included the Comprehensive Aphasia Test, an impairment-based test of the 4 main domains of language (speaking, writing, auditory comprehension, and reading) which was measured at 3 time points (baseline, immediately posttreatment at 3 weeks and follow-up at 12-week post-ICAP); and, the Communicative Effectiveness Index, a carer-reported measure of functional communication skills collected at baseline and 12 weeks.Results:A 2-way repeated measures multivariate ANOVA was conducted. We found a significant domain-by-time interaction,F=12.7,P<0.0005, indicating that the ICAP improved people with aphasia’s language scores across all 4 domains, with the largest gains in speaking (Cohen’sd=1.3). All gains were maintained or significantly improved further at 12-week post-ICAP. Importantly, patients’ functional communication, as indexed by changes on the Communicative Effectiveness Index, also significantly improved at 12-week post-ICAP,t=5.4,P<0.0005, also with a large effect size (Cohen’sd=0.9).Conclusions:People with aphasia who participated in the Queen Square ICAP made large and clinically meaningful gains on both impairment-based and functional measures of language. Gains were sustained and in some cases improved further over the subsequent 12 weeks.
      Citation: Stroke
      PubDate: 2021-06-10T09:00:05Z
      DOI: 10.1161/STROKEAHA.120.033837
       
  • Effects of Fluoxetine on Outcomes at 12 Months After Acute Stroke: Results
           From EFFECTS, a Randomized Controlled Trial

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      Authors: Erik Lundström Eva Isaksson Nina Greilert Norin Per Näsman Per Wester Björn Mårtensson Bo Norrving Håkan Wallén Jörgen Borg Graeme J. Hankey Maree L. Hackett Gillian E. Mead Martin S. Dennis Katharina S. Sunnerhagen Department of Neuroscience; NeurologyDepartment of Clinical Sciences (J.B.) Uppsala University, Sweden (E.I.). Department of Clinical Neuroscience, Neurology, Karolinska Institutet, Stockholm. (E.I.) Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm. (N.G.N.) Department of Clinical Sciences, Karolinska Institutet, Stockholm. (P.W.) Department of Clinical Neurosciences, Karolinska Institutet, Stockholm. (B.M.) Department of Clinical Sciences, Karolinska Institutet, Stockholm. (H.W.) Department of Clinical Sciences, Karolinska Institutet, Stockholm. (J.B.) Department of Neurology, Danderyd Hospital, Stockholm, Sweden (E.I.). Centre for Safety Research, KTH Royal Institute of Technology, Stockholm, Sweden (P.N.). Department of Public Health & Clinical Medicine, Umeå University, Sweden (P.W.). Department of Clinical Sciences, Neurology, Lund University, Sweden (B.N.). Medical School, Faculty of Health Physiology-Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Sweden (K.S.S.).
      First page: 3082
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The EFFECTS (Efficacy of Fluoxetine—a Randomised Controlled Trial in Stroke) recently reported that 20 mg fluoxetine once daily for 6 months after acute stroke did not improve functional outcome but reduced depression and increased fractures and hyponatremia at 6 months. The purpose of this predefined secondary analysis was to identify if any effects of fluoxetine were maintained or delayed over 12 months.Methods:EFFECTS was an investigator-led, randomized, placebo-controlled, double-blind, parallel group trial in Sweden that enrolled adult patients with stroke. Patients were randomized to 20 mg oral fluoxetine or matching placebo for 6 months and followed for another 6 months. The primary outcome was functional outcome (modified Rankin Scale), at 6 months. Predefined secondary outcomes for these analyses included the modified Rankin Scale, health status, quality of life, fatigue, mood, and depression at 12 months.Results:One thousand five hundred patients were recruited from 35 centers in Sweden between 2014 and 2019; 750 were allocated fluoxetine and 750 placebo. At 12 months, modified Rankin Scale data were available in 715 (95%) patients allocated fluoxetine and 712 (95%) placebo. The distribution of modified Rankin Scale categories was similar in the 2 groups (adjusted common odds ratio, 0.92 [95% CI, 0.76–1.10]). Patients allocated fluoxetine scored worse on memory with a median value of 89 (interquartile range, 75–100) versus 93 (interquartile range, 82–100);P=0.0021 and communication 93 (interquartile range, 82–100) versus 96 (interquartile range, 86–100);P=0.024 domains of the Stroke Impact Scale compared with placebo. There were no other differences in secondary outcomes.Conclusions:Fluoxetine after acute stroke had no effect on functional outcome at 12 months. Patients allocated fluoxetine scored worse on memory and communication on the Stroke Impact Scale compared with placebo, but this is likely to be due to chance.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT02683213.
      Citation: Stroke
      PubDate: 2021-09-01T06:30:01Z
      DOI: 10.1161/STROKEAHA.121.034705
       
  • Long-Term Incidence of Stroke and Dementia in ASCOT

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      Authors: William N. Whiteley Ajay K. Gupta Thomas Godec Somayeh Rostamian Andrew Whitehouse Judy Mackay Peter S. Sever Centre for Clinical Brain Sciences; University of Edinburgh (W.N.W.). Nuffield Department of Population Health, University of Oxford (W.N.W.). William Harvey Research Institute, Queen Mary University of London (A.K.G.). National Heart Tropical Medicine, University of London (T.G.).
      First page: 3088
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Management of stroke risk factors might reduce later dementia. In ASCOT (Anglo-Scandinavian Outcome Trial), we determined whether dementia or stroke were associated with different blood pressure (BP)–lowering regimens; atorvastatin or placebo; and mean BP, BP variability, and mean cholesterol levels.Methods:Participants with hypertension and ≥3 cardiovascular disease risk factors were randomly allocated to amlodipine- or atenolol-based BP-lowering regimen targeting BP <140/90 mm Hg for 5.5 years. Participants with total cholesterol ≤6.5 mmol/L were also randomly allocated to atorvastatin 10 mg or placebo for 3.3 years. Mean and LDL (low-density lipoprotein) cholesterol, BP, and SD of BP were calculated from 6 months to end of trial. UK participants were linked to electronic health records to ascertain deaths and hospitalization in general and mental health hospitals. Dementia and stroke were ascertained by validated code lists and within-trial ascertainment.Results:Of 8580 UK participants, 7300 were followed up to 21 years from randomization. Atorvastatin for 3.3 years had no measurable effect on stroke (264 versus 272; adjusted hazard ratio [HR], 0.92 [95% CI, 0.78–1.09];P=0.341) or dementia (238 versus 227; adjusted HR, 0.98 [95% CI, 0.82–1.18];P=0.837) compared with placebo. Mean total cholesterol was not associated with later stroke or dementia. An amlodipine-based compared with an atenolol-based regimen for 5.5 years reduced stroke (443 versus 522; adjusted HR, 0.82 [95% CI, 0.72–0.93];P=0.003) but not dementia (450 versus 465; adjusted HR, 0.94 [95% CI, 0.82–1.07];P=0.334) over follow-up. BP variability (SD mean BP) was associated with a higher risk of dementia (per 5 mm Hg HR, 1.14 [95% CI, 1.06–1.24];P<0.001) and stroke (HR, 1.21 [95% CI, 1.12–1.32];P<0.001) adjusted for mean BP.Conclusions:An amlodipine-based BP regimen reduced the long-term incidence of stroke compared with an atenolol-based regimen but had no measurable effect on dementia. Atorvastatin had no effect on either stroke or dementia. Higher BP variability was associated with a higher incidence of later dementia and stroke.
      Citation: Stroke
      PubDate: 2021-07-01T09:00:01Z
      DOI: 10.1161/STROKEAHA.120.033489
       
  • Endovascular Therapy of Anterior Circulation Tandem Occlusions: Pooled
           Analysis From the TITAN and ETIS Registries

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      Authors: Mohammad Anadani Gaultier Marnat Arturo Consoli Panagiotis Papanagiotou Raul G. Nogueira Adnan Siddiqui Marc Ribo Alejandro M. Spiotta Romain Bourcier Maeva Kyheng Julien Labreuche Adam de Havenon Igor Sibon Cyril Dargazanli Caroline Arquizan Christophe Cognard Jean-Marc Olivot René Anxionnat Gérard Audibert Mikaël Mazighi Raphaël Blanc Bertrand Lapergue Sébastien Richard Benjamin Gory Department of Neurology; Washington University School of Medicine, St. Louis (M.A., A.d.H.). Department of Diagnostic ETIS Registry Investigators Francis Turjman Michel Piotin Henrik Steglich-Arnholm Markus Holtmannspötter Christian Taschner Sebastian Eiden Diogo C. Haussen Maria Boutchakova Franziska Dorn Monika Killer-Oberpfalzer Salvatore Mangiafico Marios N. Psychogios Marc-Antoine Labeyrie Alessandra Biondi Serge Bracard Jonathan Andrew Grossberg Adrien Guenego Julien Darcourt Isabelle Vukasinovic Elisa Pomero Jason Davies Leonardo Renieri Corentin Hecker Maria Muchada Muchada Georges Rodesch Emmanuel Houdart Johanna Lockau Andreas Kastrup Hocine Redjem Daniel Behme Hussain Shallwani Maurer Christopher Gioia Mione Lisa Humbertjean Nolwenn Riou-Comte François Zhu Anne-Laure Derelle Liang Liao Michel Piotin Hocine Redjem Simon Escalard Benjamin Maïer Jean-Philippe Desilles Gabriele Ciccio Stanislas Smajda Mikael Obadia Candice Sabben Ovide Corabianu Thomas de Broucker Didier Smadja Sonia Alamowitch Olivier Ille Eric Manchon Pierre-Yves Garcia Guillaume Taylor Malek Ben Maacha Adrien Wang Serge Evrard Maya Tchikviladze Nadia Ajili David Weisenburger Lucas Gorza Oguzhan Coskun Federico Di Maria Georges Rodesh Morgan Leguen Julie Gratieux Fernando Pico Haja Rakotoharinandrasana Philippe Tassan Roxanna Poll Sylvie Marinier Florent Gariel Xavier Barreau Jérôme Berge Louis Veunac Patrice Menegon Ludovic Lucas Stéphane Olindo Pauline Renou Sharmila Sagnier Mathilde Poli Sabrina Debruxelles Thomas Tourdias Jean-Sebastien Liegey Lili Detraz Benjamin Daumas-Duport Pierre-Louis Alexandre Monica Roy Cédric Lenoble Vincent L’allinec Jean-Baptiste Girot Hubert Desal Fatiha Bechiri Serge Bracard Marc Braun Anne-Laure Derelle Romain Tonnelet Liang Liao François Zhu Emmanuelle Schmitt Sophie Planel Lisa Humbertjean Gioia Mione Jean-Christophe Lacour Gabriela Hossu Marine Beaumont Mitchelle Bailang Marie Reitter Agnès Masson Lionel Alb Adriana Tabarna Marcela Voicu Iona Podar Madalina Brezeanu Sarah Guy Vincent Costalat Grégory Gascou Pierre-Henri Lefèvre Imad Derraz Carlos Riquelme Nicolas Gaillard Isabelle Mourand Lucas Corti
      First page: 3097
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Endovascular therapy for tandem occlusion strokes of the anterior circulation is an effective and safe treatment. The best treatment approach for the cervical internal carotid artery (ICA) lesion is still unknown. In this study, we aimed to compare the functional and safety outcomes between different treatment approaches for the cervical ICA lesion during endovascular therapy for acute ischemic strokes due to tandem occlusion in current clinical practice.Methods:Individual patients’ data were pooled from the French prospective multicenter observational ETIS (Endovascular Treatment in Ischemic Stroke) and the international TITAN (Thrombectomy in Tandem Lesions) registries. TITAN enrolled patients from January 2012 to September 2016, and ETIS from January 2013 to July 2019. Patients with acute ischemic stroke due to anterior circulation tandem occlusion who were treated with endovascular therapy were included. Patients were divided based on the cervical ICA lesion treatment into stent and no-stent groups. Outcomes were compared between the two treatment groups using propensity score methods.Results:A total of 603 patients were included, of whom 341 were treated with acute cervical ICA stenting. In unadjusted analysis, the stent group had higher rate of favorable outcome (90-day modified Rankin Scale score, 0–2; 57% versus 45%) and excellent outcome (90-day modified Rankin Scale score, 0–1; 40% versus 27%) compared with the no-stent group. In inverse probability of treatment weighting propensity score–adjusted analyses, stent group had higher odds of favorable outcome (adjusted odds ratio, 1.09 [95% CI, 1.01–1.19];P=0.036) and successful reperfusion (modified Thrombolysis in Cerebral Ischemia score, 2b-3; adjusted odds ratio, 1.19 [95% CI, 1.11–1.27];P<0.001). However, stent group had higher odds of any intracerebral hemorrhage (adjusted odds ratio, 1.10 [95%, 1.02–1.19];P=0.017) but not higher rate of symptomatic intracerebral hemorrhage or parenchymal hemorrhage type 2. Subgroup analysis demonstrated heterogeneity according to the lesion type (atherosclerosis versus dissection;Pfor heterogeneity, 0.01), and the benefit from acute carotid stenting was only observed for patients with atherosclerosis.Conclusions:Patients treated with acute cervical ICA stenting for tandem occlusion strokes had higher odds of 90-day favorable outcome, despite higher odds of intracerebral hemorrhage; however, most of the intracerebral hemorrhages were asymptomatic.
      Citation: Stroke
      PubDate: 2021-08-10T09:00:01Z
      DOI: 10.1161/STROKEAHA.120.033032
       
  • Tandem Occlusions: A Tale of Two Treatments

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      Authors: Luciana Catanese Ashkan Shoamanesh Alexandre Y. Poppe Department of Medicine (Neurology); McMaster University (L.C.). Department of Medicine (Neurology), McMaster University/Population Health Research Institute (A.S.). Department of Neurosciences, Centre Hospitalier de l’Université de Montréal (A.Y.P.).
      First page: 3106
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-08-10T09:00:01Z
      DOI: 10.1161/STROKEAHA.121.036219
       
  • Thrombectomy in Extensive Stroke May Not Be Beneficial and Is Associated
           With Increased Risk for Hemorrhage

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      Authors: Lukas Meyer Matthias Bechstein Maxim Bester Uta Hanning Caspar Brekenfeld Fabian Flottmann Helge Kniep Noel van Horn Milani Deb-Chatterji Götz Thomalla Peter Sporns Leonard Leong-Litt Yeo Benjamin Yong-Qiang Tan Anil Gopinathan Andreas Kastrup Maria Politi Panagiotis Papanagiotou André Kemmling Jens Fiehler Gabriel Broocks Department of Diagnostic; Kapodistrian University of Athens, Greece (P.P.). Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore (L.L.-L.Y., B.Y.-Q.T.). Division of Interventional Radiology, Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore (A.G.). Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (L.L.-L.Y., B.Y.-Q.T., A.G.). , for the German Stroke Registry–Endovascular Treatment (GSR-ET) Silke Wunderlich Tobias Boeckh-Behrens Arno Reich Martin Wiesmann Ulrike Ernemann Till-Karsten Hauser Eberhard Siebert Christian Nolte Sarah Zweynert Georg Bohner Alexander Ludolph Karl-Heinz Henn Waltraud Pfeilschifter Marlis Wagner Joachim Röther Bernd Eckert Jörg Berrouschot Albrecht Bormann Anna Alegiani Elke Hattingen Gabor Petzold Sven Thonke Christopher Bangard Christoffer Kraemer Martin Dichgans Frank Wollenweber Lars Kellert Franziska Dorn Moriz Herzberg Marios Psychogios Jan Liman Martina Petersen Florian Stögbauer Peter Kraft Mirko Pham Michael Braun Gerhard F. Hamann Klaus Gröschel Timo Uphaus Volker Limmroth
      First page: 3109
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:This study evaluates the benefit of endovascular treatment (EVT) for patients with extensive baseline stroke compared with best medical treatment.Methods:This retrospective, multicenter study compares EVT and best medical treatment for computed tomography (CT)–based selection of patients with extensive baseline infarcts (Alberta Stroke Program Early CT Score ≤5) attributed to anterior circulation stroke. Patients were selected from the German Stroke Registry and 3 tertiary stroke centers. Primary functional end points were rates of good (modified Rankin Scale score of ≤3) and very poor outcome (modified Rankin Scale score of ≥5) at 90 days. Secondary safety end point was the occurrence of symptomatic intracerebral hemorrhage. Angiographic outcome was evaluated with the modified Thrombolysis in Cerebral Infarction Scale.Results:After 1:1 pair matching, a total of 248 patients were compared by treatment arm. Good functional outcome was observed in 27.4% in the EVT group, and in 25% in the best medical treatment group (P=0.665). Advanced age (adjusted odds ratio, 1.08 [95% CI, 1.05–1.10],P<0.001) and symptomatic intracerebral hemorrhage (adjusted odds ratio, 6.35 [95% CI, 2.08–19.35],P<0.001) were independently associated with very poor outcome. Mortality (43.5% versus 28.9%,P=0.025) and symptomatic intracerebral hemorrhage (16.1% versus 5.6%,P=0.008) were significantly higher in the EVT group. The lowest rates of good functional outcome (≈15%) were observed in groups of failed and partial recanalization (modified Thrombolysis in Cerebral Infarction Scale score of 0/1–2a), whereas patients with complete recanalization (modified Thrombolysis in Cerebral Infarction Scale score of 3) with recanalization attempts ≤2 benefitted the most (modified Rankin Scale score of ≤3:42.3%,P=0.074) compared with best medical treatment.Conclusions:In daily clinical practice, EVT for CT–based selected patients with low Alberta Stroke Program Early CT Score anterior circulation stroke may not be beneficial and is associated with increased risk for hemorrhage and mortality, especially in the elderly. However, first- or second-pass complete recanalization seems to reveal a clinical benefit of EVT highlighting the vulnerability of the low Alberta Stroke Program Early CT Score subgroup.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT03356392.
      Citation: Stroke
      PubDate: 2021-09-02T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033101
       
  • Thrombectomy for Patients With Large Infarct Core in Practice: Where
           Should the Pendulum Swing'

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      Authors: Thabele M. Leslie-Mazwi Dorothea Altschul Claus Z. Simonsen Departments of Neurology; Neurosurgeons of NJ, New York University, Ridgewood (D.A.). Department of Neurology, Aarhus University Hospital, Denmark (C.Z.S.).
      First page: 3118
      Abstract: Stroke, Ahead of Print.

      Citation: Stroke
      PubDate: 2021-09-02T09:00:02Z
      DOI: 10.1161/STROKEAHA.121.034754
       
  • Stroke Prevention by Anticoagulants in Daily Practice Depending on Atrial
           Fibrillation Pattern and Clinical Risk Factors

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      Authors: Lamiae Grimaldi-Bensouda Jean-Yves Le Heuzey Jean Ferrières Didier Leys Jean-Marc Davy Mikel Martinez Olivia Dialla Didier Smadja Norbert Nighoghossian Jacques Benichou Clementine Nordon Emmanuel Touzé Lucien Abenhaim The PGRx Study Group; Paris, France (L.G.-B.). Department of Pharmacology, Hospital Group Paris-Saclay, Assistance Publique- Hôpitaux de Paris; UFR des Sciences de la Santé, University Paris-Saclay, France (L.G.-B.). Arrhythmia Unit, Georges Pompidou European Hospital Tropical Medicine, London, United Kingdom (L.A.).
      First page: 3121
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The objective of the study was to assess the effectiveness of individual direct oral anticoagulants versus vitamin K antagonists for primary prevention of stroke (ischemic and hemorrhagic) in routine clinical practice in patients with various clinical risk factors depending on their atrial fibrillation (AF) patterns.Methods:A nested case-referent study was conducted using data from 2 national registries of patients with stroke and AF. Stroke cases with previous history of AF were matched to up to 2 randomly selected referent patients with AF and no stroke. The association of individual anticoagulant use with ischemic or hemorrhagic stroke was studied in patients with or without permanent AF using multivariable conditional logistic models, controlled for clinically significant risk factors and multiple other cardiovascular risk factors.Results:In total, 2586 stroke cases with previous AF and 4810 nonstroke referent patients with AF were retained for the study. Direct oral anticoagulant users had lower odds of stroke of any type than vitamin K antagonist users: the adjusted-matched OR for ischemic stroke were 0.70 (95% CI, 0.50–0.98) for dabigatran, 0.68 (95% CI, 0.53–0.86) for rivaroxaban, and 0.73 (95% CI, 0.52–1.02) for apixaban while for hemorrhagic stroke they were 0.31 (95% CI, 0.14–0.68), 0.64 (95% CI, 0.39–1.06), and 0.70 (95% CI, 0.33–1.49), respectively. The effects of individual direct oral anticoagulants relative to vitamin K antagonists were similar in permanent AF and nonpermanent AF patients.Conclusions:Similar results were observed for each direct oral anticoagulant in real life as those observed in the pivotal clinical trials. The pattern of AF did not affect the outcome.
      Citation: Stroke
      PubDate: 2021-07-13T09:00:00Z
      DOI: 10.1161/STROKEAHA.120.032704
       
  • Clinical Outcomes in Atrial Fibrillation Patients With a History of Cancer
           Treated With Non-Vitamin K Antagonist Oral Anticoagulants: A Nationwide
           Cohort Study

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      Authors: Yi-Hsin Chan Tze-Fan Chao Hsin-Fu Lee Shao-Wei Chen Pei-Ru Li Jia-Rou Liu Lung-Sheng Wu Shang-Hung Chang Yung-Hsin Yeh Chi-Tai Kuo Lai-Chu See Gregory Y.H. Lip The Cardiovascular Department; Chang Gung Memorial Hospital, Linkou, Taiwan. (Y.-H.C., L.-S.W., S.-H.C., Y.-H.Y., C.-T.K.) Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan. (Y.-H.C.) New Taipei City Municipal Tucheng Hospital, Chang Gung Memorial Hospital, Linkou, Taiwan. (H.-F.L.) Division of Thoracic Liverpool Heart & Chest Hospital, United Kingdom (G.Y.H.L.).
      First page: 3132
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Data on clinical outcomes for nonvitamin K antagonist oral anticoagulant (NOACs) and warfarin in patients with atrial fibrillation and cancer are limited, and patients with active cancer were excluded from randomized trials. We investigated the effectiveness and safety for NOACs versus warfarin among patients with atrial fibrillation with cancer.Methods:In this nationwide retrospective cohort study from Taiwan National Health Insurance Research Database, we identified a total of 6274 and 1681 consecutive patients with atrial fibrillation with cancer taking NOACs and warfarin from June 1, 2012, to December 31, 2017, respectively. Propensity score stabilized weighting was used to balance covariates across study groups.Results:There were 1031, 1758, 411, and 3074 patients treated with apixaban, dabigatran, edoxaban, and rivaroxaban, respectively. After propensity score stabilized weighting, NOAC was associated with a lower risk of major adverse cardiovascular events (hazard ratio, 0.63 [95% CI, 0.50–0.80];P=0.0001), major adverse limb events (hazard ratio, 0.41 [95% CI, 0.24–0.70];P=0.0010), venous thrombosis (hazard ratio, 0.37 [95% CI, 0.23–0.61];P<0.0001), and major bleeding (hazard ratio, 0.73 [95% CI, 0.56–0.94];P=0.0171) compared with warfarin. The outcomes were consistent with either direct thrombin inhibitor (dabigatran) or factor Xa inhibitor (apixaban, edoxaban, and rivaroxaban) use, among patients with stroke history, and among patients with different type of cancer and local, regional, or metastatic stage of cancer (Pinteraction >0.05). When compared with warfarin, NOAC was associated with lower risk of major adverse cardiovascular event, and venous thrombosis in patients aged <75 but not in those aged ≥75 years (Pinteraction <0.05).Conclusions:Thromboprophylaxis with NOACs rather than warfarin should be considered for the majority of the atrial fibrillation population with cancer.
      Citation: Stroke
      PubDate: 2021-07-08T09:00:01Z
      DOI: 10.1161/STROKEAHA.120.033470
       
  • Lipid-Lowering Therapy and Hemorrhagic Stroke Risk: Comparative
           Meta-Analysis of Statins and PCSK9 Inhibitors

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      Authors: Borja E. Sanz-Cuesta Jeffrey L. Saver Department of Neurology; Olive View – UCLA Medical Center, Sylmar, CA (B.E.S.-C). Department of Neurology, UCLA, Los Angeles, CA (J.L.S.).
      First page: 3142
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Statins were shown to increase hemorrhagic stroke (HS) in patients with a first cerebrovascular event in 2006 (SPARCL), likely due to off-target antithrombotic effects, but continued to sometimes be used in patients with elevated HS risk due to absence of alternative medications. Recently, the PCSK9Is (proprotein convertase subtilisin kexin 9 inhibitors) have become available as a potent lipid-lowering class with potentially less hemorrhagic propensity.Methods:We performed a systematic comparative meta-analysis assessing HS rates across all completed statin and PCSK9I randomized clinical trials with treatment >3 months, following PRISMA guidelines. In addition to HS rates across all trials, causal relation was probed by evaluating for dose-response relationships by medication (low versus high medication dose/potency) and by presence and type of preceding brain vascular events at inception (none versus ischemic stroke/transient ischemic attack versus HS).Results:The systematic review identified 36 statin randomized clinical trials (204 918 patients) and 5 PCSK9I randomized clinical trials (76 140 patients). Across all patient types and all medication doses/potencies, statins were associated with increased HS: relative risk 1.15,P=0.04; PCSK9Is were not (P=0.77). In the medication dose/potency analysis, higher dose/potency statins (7 trials, 62 204 patients) were associated with magnified HS risk: relative risk, 1.53;P=0.002; higher dose/potency PCSK9Is (1 trial, 27 564 patients) were not (P=0.99). In the type of index brain vascular injury analysis for statins (5 trials, 9772 patients), prior ischemic stroke/transient ischemic attack was associated with a magnified risk of HS: relative risk, 1.43;P=0.04; and index intracerebral hemorrhage was associated with an extremely high effect estimate of risk of recurrent HS: hazard ratio, 4.06. For PCSK9Is, prior ischemic stroke/transient ischemic attack (1 trial, 5337 patients) was not associated with increased HS risk (P=0.97).Conclusions:Statins increase the risk of HS in a medication dose- and type of index brain vascular injury-dependent manner; PCSK9Is do not increase HS risk. PCSK9Is may be a preferred lipid-lowering medication class in patients with elevated HS risk, including patients with prior HS.
      Citation: Stroke
      PubDate: 2021-06-22T09:00:04Z
      DOI: 10.1161/STROKEAHA.121.034576
       
  • Association of Oral Anticoagulation With Stroke in Atrial Fibrillation or
           Heart Failure: A Comparative Meta-Analysis

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      Authors: Catriona Reddin Conor Judge Elaine Loughlin Robert Murphy Maria Costello Alberto Alvarez John Ferguson Andrew Smyth Michelle Canavan Martin J. O’Donnell HRB-Clinical Research Facility; National University of Ireland Galway. (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.) Translational Medical Device Laboratory, National University of Ireland Galway. (C.J.) Department of Geriatric Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.). Wellcome Trust – HRB, Irish Clinical Academic Training (C.J.).
      First page: 3151
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Atrial fibrillation and heart failure with reduced ejection fraction (HFrEF) are common sources of cardioembolism. While oral anticoagulation is strongly recommended for atrial fibrillation, there are marked variations in guideline recommendations for HFrEF due to uncertainty about net clinical benefit. This systematic review and meta-analysis evaluates the comparative association of oral anticoagulation with stroke and other cardiovascular risk in populations with atrial fibrillation or HFrEF in sinus rhythm and identify factors mediating different estimates of net clinical benefit.Methods:PubMed and Embase were searched from database inception to November 20, 2019 for randomized clinical trials comparing oral anticoagulation to control. A random-effects meta-analysis was used to estimate a pooled treatment-effect overall and within atrial fibrillation and HFrEF trials. Differences in treatment effect were assessed by estimating I2among all trials and testing the between-trial-populationP-interaction. The primary outcome measure was all stroke. Secondary outcome measures were ischemic stroke, hemorrhagic stroke, mortality, myocardial infarction, and major hemorrhage.Results:Twenty-one trials were eligible for inclusion, 15 (n=19 332) in atrial fibrillation (mean follow-up: 23.1 months), and 6 (n=9866) in HFrEF (mean follow-up: 23.9 months). There were differences in primary outcomes between trial populations, with all-cause mortality included for 95.2% of HFrEF trial population versus 0.38% for atrial fibrillation. Mortality was higher in controls groups of HFrEF populations (19.0% versus 9.6%) but rates of stroke lower (3.1% versus 7.0%) compared with atrial fibrillation. The association of oral anticoagulation with all stroke was consistent for atrial fibrillation (odds ratio, 0.51 [95% CI, 0.42–0.63]) and HFrEF (odds ratio, 0.61 [95% CI, 0.47–0.79]; I2=12.4%;Pinteraction=0.31). There were no statistically significant differences in the association of oral anticoagulation with cardiovascular events, mortality or bleeding between populations.Conclusions:The relative association of oral anticoagulation with stroke risk, and other cardiovascular outcomes, is similar for patients with atrial fibrillation and HFrEF. Differences in the primary outcomes employed by trials in HFrEF, compared with atrial fibrillation, may have contributed to differing conclusions of the relative efficacy of oral anticoagulation.
      Citation: Stroke
      PubDate: 2021-07-20T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033910
       
  • Mobile Stroke Units Facilitate Prehospital Management of Intracerebral
           Hemorrhage

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      Authors: S. Regan Cooley Henry Zhao Bruce C.V. Campbell Leonid Churilov Skye Coote Damien Easton Francesca Langenberg Michael Stephenson Bernard Yan Patricia M. Desmond Peter J. Mitchell Mark W. Parsons Geoffrey A. Donnan Stephen M. Davis Nawaf Yassi Departments of Medicine; Eliza Hall Institute of Medical Research, Australia (N.Y.). , on behalf of the Melbourne Mobile Stroke Unit Collaboration Karen Smith Stephen Bernard Dominique A. Cadilhac Joosup Kim Christopher F. Bladin Douglas E. Crompton Helen M. Dewey Lauren M. Sanders Tissa Wijeratne Geoffrey C. Cloud Duncan M. Brooks Hamed Asadi Vincent Thijs Ronil V. Chandra Henry Ma Thanh Phan Andrew Bivard Richard J. Dowling Nawaf Yassi
      First page: 3163
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Mobile stroke units (MSUs) improve reperfusion therapy times in acute ischemic stroke (AIS). However, prehospital management options for intracerebral hemorrhage (ICH) are less established. We describe the initial Melbourne MSU experience in ICH.Methods:Consecutive patients with ICH and AIS treated by the Melbourne MSU were included. We describe demographics, proportions of patients receiving specific therapies, and bypass to comprehensive/neurosurgical centers. We also compare operational time metrics between patients with MSU-ICH and MSU-AIS.Results:During a 2-year period, the Melbourne MSU managed 49 patients with ICH, mean (SD) age 74 (12) years, median (interquartile range) National Institutes of Health Stroke Scale 17 (12–20). Intravenous antihypertensives were the commonest treatment provided (46.9%). Bypass of a primary center to a comprehensive center with neurosurgical expertise occurred in 32.7% of patients with MSU-ICH compared with 20.5% of patients with MSU-AIS. Compared with patients with MSU-AIS, patients with MSU-ICH had faster onset-to-emergency-call, and onset-to-scene-arrival times at the median and 75th percentiles.Conclusions:MSUs can facilitate ultra-early ICH diagnosis, management, and triage.
      Citation: Stroke
      PubDate: 2021-06-30T09:00:01Z
      DOI: 10.1161/STROKEAHA.121.034592
       
  • Revisiting the Proportional Recovery Model in View of the Ceiling Effect
           of Fugl-Meyer Assessment

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      Authors: Hyun Haeng Lee Deog Young Kim Min Kyun Sohn Yong-Il Shin Gyung-Jae Oh Yang-Soo Lee Min Cheol Joo So Young Lee Junhee Han Jeonghoon Ahn Won Hyuk Chang Ilyoel Kim Soo Mi Choi Jongmin Lee Yun-Hee Kim Department of Rehabilitation Medicine; Konkuk University School of Medicine, Konkuk University Medical Center, Seoul, Korea (H.H.L., J.L.). Department Research, Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, South Korea (Y.-H.K.).
      First page: 3167
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:The aim of this study was to verify the validity of the proportional recovery model in view of the ceiling effect of the Fugl-Meyer Assessment.Methods:We reviewed the medical records of patients enrolled in the Korean Stroke Cohort for Functioning and Rehabilitation between August 2012 and May 2015. Recovery proportion was defined as the actual change in Fugl-Meyer Assessment score of the upper extremity between 7 days and 6 months poststroke, relative to the initial neurological impairment. We then used logistic regression to identify clinical factors attributable to a ceiling effect of the Fugl-Meyer Assessment score of the upper extremity and propensity score matching to verify the validity of the proportional recovery rule.Results:We screened 10 636 patients and analyzed 849 patients (mean age, 65.4±11.9 years; female, 320 [37.7%]) with first-ever ischemic stroke. We found, through logistic regression analysis, that a one-unit increase in the initial neurological impairment and the age at stroke onset affected the odds ratio (1.0386 and 0.9736, respectively) of achieving the full Fugl-Meyer Assessment score of the upper limb at 6 months poststroke. We also demonstrated, through propensity score matching, that the difference in initial neurological impairment of the upper extremity resulted in discrepancy of the recovery proportion (0.92±0.20 [0–1] versus 0.81±0.31 [0–1],P<0.001).Conclusions:We demonstrated that the ceiling effect of the Fugl-Meyer Assessment score of the upper extremity is pronounced in patients with mild initial motor deficits of the upper extremity and that the recovery proportion varies according to the initial motor deficit of the upper limb using logistic regression analysis and propensity score matching, respectively. These results suggest that the proportional recovery model is not valid.
      Citation: Stroke
      PubDate: 2021-06-17T09:00:04Z
      DOI: 10.1161/STROKEAHA.120.032409
       
  • Overnight Rostral Fluid Shifts Exacerbate Obstructive Sleep Apnea After
           Stroke

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      Authors: Devin L. Brown Azadeh Yadollahi Kevin He Yuliang Xu Bryan Piper Erin Case Ronald D. Chervin Lynda D. Lisabeth Stroke Program; University of Michigan, Ann Arbor. (D.L.B., L.D.L.) Sleep Disorders Center Department of Neurology, University of Michigan, Ann Arbor. (R.D.C.) Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor. (K.H., Y.X.) Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor. (E.C., L.D.L.) University Health Network-Toronto Rehabilitation Institute, Canada (A.Y., B.P.). Institute of Biomaterials & Biomedical Engineering, University of Toronto, Canada (A.Y., B.P.).
      First page: 3176
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Overnight shifts of fluid from lower to upper compartments exacerbate obstructive sleep apnea (OSA) in some OSA populations. Given the high prevalence of OSA after stroke, decreased mobility and use of IV fluids among hospitalized patients with stroke, and improvement in OSA in the months after stroke, we hypothesized that overnight fluid shifts occur and are associated with OSA among patients with subacute ischemic stroke.Methods:Within a population-based project, we performed overnight sleep apnea tests (ApneaLink Plus) during ischemic stroke hospitalizations. Before sleep that evening, and the following morning before rising from bed, we assessed neck and calf circumference, and leg fluid volume (bioimpedance spectroscopy). The average per subject overnight change in the 3 fluid shift measurements was calculated and compared with zero. Linear regression was used to test the crude association between each of the 3 fluid shift measurements and the respiratory event index (REI).Results:Among the 292 participants, mean REI was 24 (SD=18). Within individuals, calf circumference decreased on average by 0.66 cm (SD=0.75 cm,P<0.001), leg fluid volume decreased by a mean of 135.6 mL (SD=132.8 mL,P<0.001), and neck circumference increased by 0.20 cm (SD=1.71 cm,P=0.07). In men, when the overnight change of calf circumference was negative, an interquartile range (0.8 cm) decrease in calf circumference overnight was significantly associated with a 25.1% increase in REI (P=0.02); the association was not significant in women. The relationship between overnight change in leg fluid volume and REI was U shaped.Conclusions:This population-based, multicenter, cross-sectional study showed that in hospitalized patients with ischemic stroke, nocturnal rostral fluid shifts occurred, and 2 of the 3 measures were associated with greater OSA severity. Interventions that limit overnight fluid shifts should be tested as potential treatments for OSA among patients with subacute ischemic stroke.
      Citation: Stroke
      PubDate: 2021-07-16T09:00:01Z
      DOI: 10.1161/STROKEAHA.120.032688
       
  • Marijuana Use and the Risk of Early Ischemic Stroke: The Stroke Prevention
           in Young Adults Study

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      Authors: Tara Dutta Kathleen A. Ryan Oluwatosin Thompson Haley Lopez Natalie Fecteau Mary J. Sparks Seemant Chaturvedi Carolyn Cronin Prachi Mehndiratta Joel R. Nunez Gonzalez Michael Phipps Marcella Wozniak Patrick F. McArdle Steven J. Kittner John W. Cole Department of Neurology, University of Maryland School of Medicine, Baltimore. (T.D; O.T, H.L, N.F, M.J.S, S.C, C.C, P.M, J.R.N.G, M.P, M.W, S.J.K, J.W.C.) Department of Medicine, University of Maryland School of Medicine, Baltimore. (K.A.R, P.F.M.) VA Maryland Health Care System, Baltimore (K.A.R, H.L, N.F, S.C, C.C, M.P, M.W, S.J.K, J.W.C.).
      First page: 3184
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Few studies have examined the dose-response and temporal relationships between marijuana use and ischemic stroke while controlling for important confounders, including the amount of tobacco smoking. The purpose of our study was to address these knowledge gaps.Methods:A population-based case-control study with 1090 cases and 1152 controls was used to investigate the relationship of marijuana use and early-onset ischemic stroke. Cases were first-ever ischemic stroke between the ages of 15 and 49 identified from 59 hospitals in the Baltimore-Washington region. Controls obtained by random digit dialing from the same geographic region were frequency-matched to cases by age, sex, region of residence and, except for the initial study phase, race. After excluding subjects with cocaine and other vasoactive substance use, the final study sample consisted of 751 cases and 813 controls. All participants underwent standardized interviews to characterize stroke risk factors and marijuana use. Unconditional logistic regression analysis was used to assess the relationships between marijuana use and risk of ischemic stroke, adjusting for age, sex, race, study phase, the amount of current tobacco smoking, current alcohol use, hypertension, and diabetes.Results:After adjusting for other risk factors, including the amount of current tobacco smoking, marijuana use was not associated with ischemic stroke, regardless of the timing of use in relationship to the stroke, including ever use, use within 30 days, and use within 24 hours. There was a nonsignificant trend towards increased stroke risk among those who smoked marijuana at least once a week (odds ratio, 1.9 [95% CI, 0.8–4.9]).Conclusions:These analyses do not demonstrate an association between marijuana use and an increased risk of early-onset ischemic stroke, although statistical power was limited for assessing the association among very heavy users.
      Citation: Stroke
      PubDate: 2021-07-16T09:00:01Z
      DOI: 10.1161/STROKEAHA.120.032811
       
  • Different Predictive Factors for Early Neurological Deterioration Based on
           the Location of Single Subcortical Infarction: Early Prognosis in Single
           Subcortical Infarction

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      Authors: Ki-Woong Nam Hyung-Min Kwon Yong-Seok Lee Department of Neurology; Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Korea. Department of Neurology, Seoul National University College of Medicine, Korea.
      First page: 3191
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Patients with single subcortical infarctions (SSIs) have relatively a favorable prognosis, but they often experience early neurological deterioration (END). In this study, we compared the predictors for END in patients with SSI according to the location of the lesion.Methods:We included consecutive patients with SSIs within 72 hours of symptom onset presenting between 2010 and 2016. END was defined as an increase of ≥2 in the total National Institutes of Health Stroke Scale (NIHSS) score or ≥1 in the motor NIHSS score within the first 72 hours of admission. Along with the analysis of all patients with SSI, we also analyzed the predictors for END in proximal/distal SSI patients and anterior/posterior circulation SSI patients.Results:A total of 438 patients with SSI were evaluated. In multivariable analysis, initial NIHSS score (adjusted odds ratio, 1.36 [95% CI, 1.15–1.60]), pulsatility index (adjusted odds ratio, 1.25 [95% CI, 1.03–1.52]), parent artery disease (adjusted odds ratio, 2.14 [95% CI, 1.06–4.33]), and neutrophil-to-lymphocyte ratio (adjusted odds ratio, 1.24 [95% CI, 1.04–1.49]) were positively associated with END. In patients with proximal SSI, initial NIHSS score, pulsatility index, parent artery disease, and neutrophil-to-lymphocyte ratio showed positive associations with END. Meanwhile, no variable related to END was found in the distal SSI group. When we compared the predictors for END based on the involved vascular territory, higher initial NIHSS score and neutrophil-to-lymphocyte ratio were significantly associated with END in patients with anterior circulation SSIs. On the contrary, higher pulsatility index values and the presence of parent artery disease were independent predictors for END in patients with SSIs in the posterior circulation.Conclusions:Initial NIHSS score, pulsatility index, parent artery disease, and neutrophil-to-lymphocyte ratio are associated with END in patients with SSIs. The frequency and predictors for END differ depending on the location of the SSI.
      Citation: Stroke
      PubDate: 2021-06-28T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.032966
       
  • Outcomes of Carotid Revascularization in the Treatment of Restenosis After
           Prior Carotid Endarterectomy

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      Authors: Nadin Elsayed Ganesh Ramakrishnan Isaac Naazie Sharvil Sheth Mahmoud B. Malas Division of Vascular; Endovascular Surgery, St Luke’s University Health Network, Bethlehem, PA (S.S.).
      First page: 3199
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:Restenosis after carotid endarterectomy (CEA) is associated with an increased risk of ipsilateral stroke. The optimal procedural modality for this indication has yet to be determined. Here, we evaluate the in-hospital outcomes of transcarotid artery revascularization (TCAR), redo-CEA, and transfemoral carotid artery stenting (TFCAS) in a large contemporary cohort of patients who underwent treatment for restenosis after CEA.Methods:We performed a retrospective analysis of all patients in the vascular quality initiative database who underwent TCAR, redo-CEA, or TFCAS after ipsilateral CEA between September 2016 and April 2020. Patients with prior ipsilateral CAS were excluded from this analysis. In-hospital outcomes following TCAR versus CEA and TCAR versus TFCAS were evaluated using multivariate logistic regression analysis.Results:A total of 4425 patients were available for this analysis. There were 963 (21.8%) redo-CEA, 1786 (40.4%) TFCAS, and 1676 (37.9%) TCAR. TCAR was associated with lower odds of in-hospital stroke/death (odds ratio [OR], 0.41 [95% CI, 0.24–0.70],P=0.021), stroke (OR, 0.46 [95% CI, 0.23–0.93],P=0.03), myocardial infarction (MI; OR, 0.32 [95% CI, 0.14–0.73],P=0.007), stroke/transient ischemic attack (OR, 0.42 [95% CI, 0.24–0.74],P=0.002), and stroke/death/MI (OR, 0.41 [95% CI, 0.24–0.70],P=0.001) when compared with redo-CEA. There was no significant difference in the odds of death between the 2 groups (OR, 0.99 [95% CI, 0.28–3.5],P=0.995). TCAR was also associated with lower odds of stroke/transient ischemic attack (OR, 0.37 [95% CI, 0.18–0.74],P=0.005) when compared with TFCAS. There was no significant difference in the odds of stroke, death, MI, stroke/death, or stroke/death/MI between TCAR and TFCAS.Conclusions:TCAR was associated with significantly lower odds of in-hospital stroke, MI, stroke/transient ischemic attack, stroke/death, and stroke/death/MI when compared with redo-CEA and lower odds of in-hospital stroke/transient ischemic attack when compared with TFCAS. Additional long-term studies are warranted to establish the role of TCAR for the treatment of restenosis after CEA.
      Citation: Stroke
      PubDate: 2021-07-20T09:00:02Z
      DOI: 10.1161/STROKEAHA.120.033667
       
  • Rescue of Neglect and Language Impairment After Stroke Thrombectomy

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      Authors: Shashvat M. Desai Konark Malhotra Guru Ramaiah Daniel A. Tonetti Waqas Haq Tudor G. Jovin Ashutosh P. Jadhav Department of Neurology, University of Pittsburgh Medical Center, PA. (S.M.D; G.R, W.H, A.P.J.) Department of Neurosurgery, University of Pittsburgh Medical Center, PA. (D.A.T, A.P.J.) Department of Neurology, Allegheny Health Network, Pittsburgh, PA (K.M.). Department of Neurology, Cooper University Hospital, Camden, NJ (T.G.J.).
      First page: 3209
      Abstract: Stroke, Ahead of Print.
      BACKGROUND AND PURPOSE:Although National Institutes of Health Stroke Scale scores provide an objective measure of clinical deficits, data regarding the impact of neglect or language impairment on outcomes after mechanical thrombectomy (MT) is lacking. We assessed the frequency of neglect and language impairment, rate of their rescue by MT, and impact of rescue on clinical outcomes.Methods:This is a retrospective analysis of a prospectively collected database from a comprehensive stroke center. We assessed right (RHS) and left hemispheric strokes (LHS) patients with anterior circulation large vessel occlusion undergoing MT to assess the impact of neglect and language impairment on clinical outcomes, respectively. Safety and efficacy outcomes were compared between patients with and without rescue of neglect or language impairment.Results:Among 324 RHS and 210 LHS patients, 71% of patients presented with neglect whereas 93% of patients had language impairment, respectively. Mean age was 71±15, 56% were females, and median National Institutes of Health Stroke Scale score was 16 (12–20). At 24 hours, MT resulted in rescue of neglect in 31% of RHS and rescue of language impairment in 23% of LHS patients, respectively. RHS patients with rescue of neglect (56% versus 34%,P<0.001) and LHS patients with rescue of language impairment (64 % versus 25%,P<0.01) were observed to have a higher rate of functional independence compared to patients without rescue. After adjusting for confounders including 24-hour National Institutes of Health Stroke Scale, rescue of neglect among RHS patients was associated with functional independence (P=0.01) and lower mortality (P=0.01). Similarly, rescue of language impairment among LHS patients was associated with functional independence (P=0.02) and lower mortality (P=0.001).ConclusionS:Majority of LHS-anterior circulation large vessel occlusion and of RHS-anterior circulation large vessel occlusion patients present with the impairment of language and neglect, respectively. In comparison to 24-hour National Institutes of Health Stroke Scale, rescue of these deficits by MT is an independent and a better predictor of functional independence and lower mortality.
      Citation: Stroke
      PubDate: 2021-07-16T09:00:01Z
      DOI: 10.1161/STROKEAHA.121.034243
       
  • Prediction of Independent Walking in People Who Are Nonambulatory Early
           After Stroke: A Systematic Review

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      Authors: Elisabeth Preston Louise Ada Rosalyn Stanton Niruthikha Mahendran Catherine M. Dean Faculty of Health; University of Canberra, Australia (E.P.). Faculty of Health Sciences, University of Sydney, Australia (L.A.). Canberra Health Services, Physiotherapy, Australia (R.S.). School of Health Human Sciences, Macquarie University, Sydney, Australia (C.M.D.).
      First page: 3217
      Abstract: Stroke, Ahead of Print.
      Background and Purpose:One systematic review has examined factors that predict walking outcome at one month in initially nonambula