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Acta Neurologica Scandinavica Feb 2022Severity of leukoaraiosis may mediate outcomes after reperfusion therapy in acute ischaemic stroke (AIS) patients. However, the level of the association remains poorly... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
Severity of leukoaraiosis may mediate outcomes after reperfusion therapy in acute ischaemic stroke (AIS) patients. However, the level of the association remains poorly understood. We performed a meta-analysis to investigate the impact of leukoaraiosis severity on functional outcome, survival, haemorrhagic complications, and procedural success in AIS patients treated with intravenous thrombolysis and/or endovascular thrombectomy.
MATERIALS AND METHODS
PubMed, EMBASE and the Cochrane library were searched for studies on leukoaraiosis in AIS receiving reperfusion therapy. A random-effects meta-analysis was conducted for post-reperfusion outcomes in AIS patients with absent-to-mild leukoaraiosis and moderate-to-severe leukoaraiosis. The strength of association between moderate-to-severe leukoaraiosis and poor outcomes was quantified using odds ratios (OR).
RESULTS
A total of 15 eligible studies involving 6460 patients (1451 with moderate-to-severe leukoaraiosis and 5009 with absent-to-mild leukoaraiosis) were included in the meta-analysis. Moderate-to-severe leukoaraiosis was significantly associated with poor 90-day functional outcome (OR 3.16; 95% confidence interval (CI) 2.69-3.72; p < .0001), 90-day mortality (OR 3.11; 95% CI 2.27-4.26; p < .0001) and increased risk of symptomatic intracerebral haemorrhage (OR 1.69; 95% CI 1.24-2.32; p = .001) after reperfusion therapy. Overall, no significant association of leukoaraiosis severity with haemorrhagic transformation (HT) and angiographic recanalization status were observed. However, subgroup analysis revealed a significant association of WML severity with HT in patients receiving EVT.
CONCLUSION
Leukoaraiosis is a useful prognostic biomarker in AIS. Patients with moderate-to-severe leukoaraiosis on baseline imaging are likely to have worse clinical and safety outcomes after reperfusion therapy.
Topics: Brain Ischemia; Endovascular Procedures; Humans; Ischemic Stroke; Leukoaraiosis; Reperfusion; Severity of Illness Index; Stroke; Thrombolytic Therapy; Treatment Outcome
PubMed: 34418060
DOI: 10.1111/ane.13519 -
Stroke Nov 2022Quality indicators (QIs) are an accepted tool for measuring a hospital's performance in routine care. We examined national trends in adherence to the QIs developed by...
BACKGROUND
Quality indicators (QIs) are an accepted tool for measuring a hospital's performance in routine care. We examined national trends in adherence to the QIs developed by the Close The Gap-Stroke program by combining data from the health insurance claims database and electronic medical records, and the association between adherence to these QIs and early outcomes in patients with acute ischemic stroke in Japan.
METHODS
In the present study, patients with acute ischemic stroke who received acute reperfusion therapy in 351 Close The Gap-Stroke-participating hospitals were analyzed retrospectively. The primary outcomes were changes in trends for adherence to the defined QIs by difference-in-difference analysis and the effects of adherence to distinct QIs on in-hospital outcomes at the individual level. A mixed logistic regression model was adjusted for patient and hospital characteristics (eg, age, sex, number of beds) and hospital units as random effects.
RESULTS
Between 2013 and 2017, 21 651 patients (median age, 77 years; 43.0% female) were assessed. Of the 25 defined measures, marked and sustainable improvement in the adherence rates was observed for door-to-needle time, door-to-puncture time, proper use of endovascular thrombectomy, and successful revascularization. The in-hospital mortality rate was 11.6%. Adherence to 14 QIs lowered the odds of in-hospital mortality (odds ratio [95% CI], door-to-needle <60 min, 0.80 [0.69-0.93], door-to-puncture <90 min, 0.80 [0.67-0.96], successful revascularization, 0.40 [0.34-0.48]), and adherence to 11 QIs increased the odds of functional independence (modified Rankin Scale score 0-2) at discharge.
CONCLUSIONS
We demonstrated national marked and sustainable improvement in adherence to door-to-needle time, door-to-puncture time, and successful reperfusion from 2013 to 2017 in Japan in patients with acute ischemic stroke. Adhering to the key QIs substantially affected in-hospital outcomes, underlining the importance of monitoring the quality of care using evidence-based QIs and the nationwide Close The Gap-Stroke program.
Topics: Humans; Female; Aged; Male; Quality Indicators, Health Care; Retrospective Studies; Ischemic Stroke; Time-to-Treatment; Treatment Outcome; Stroke; Reperfusion; Thrombectomy; Endovascular Procedures; Brain Ischemia
PubMed: 35971841
DOI: 10.1161/STROKEAHA.121.038483 -
EuroIntervention : Journal of EuroPCR... Nov 2023Reperfusion therapy is challenging in the elderly. Catheter-directed therapies are an alternative for higher-risk pulmonary embolism (PE) patients if systemic...
BACKGROUND
Reperfusion therapy is challenging in the elderly. Catheter-directed therapies are an alternative for higher-risk pulmonary embolism (PE) patients if systemic thrombolysis (ST) is contraindicated or has failed. Their safety has not been evaluated in specific vulnerable populations.
AIMS
We aimed to assess the safety of reperfusion therapies in elderly and frail patients in the real world.
METHODS
In the US Nationwide Inpatient Sample from 2016 to 2020, we identified hospitalisations of patients ≥65 years with PE and defined a frailty subgroup using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. We investigated reperfusion therapies (ST, catheter-directed thrombolysis [CDT], catheter-based thrombectomy [CBT], surgical embolectomy [SE]) and their associated safety outcomes (overall and major bleeding).
RESULTS
Among 980,245 hospitalisations of patients ≥65 years with PE (28.0% frail), reperfusion therapies were used in 4.9% (17.6% among high-risk PE). ST utilisation remained stable, while the use of catheter-directed therapies increased from 1.7% in 2016 to 3.2% in 2020. Among all hospitalisations with reperfusion, CDT, compared to ST, was associated with reduced major bleeding (5.8% vs 12.2%, odds ratio [OR] 0.58, 95% confidence interval [CI]: 0.49-0.70); these results also applied to frail patients. CBT, compared to SE, was also associated with reduced major bleeding (11.0% vs 22.4%, OR 0.63, 95% CI: 0.43-0.91), but not among frail patients. These differences were particularly significant in patients with non-high-risk PE. Differences persisted for overall bleeding as well.
CONCLUSIONS
Catheter-directed therapies may be a safer alternative to classical reperfusion therapies for elderly and frail patients with PE requiring reperfusion treatment.
Topics: Humans; Aged; Thrombolytic Therapy; Fibrinolytic Agents; Frailty; Treatment Outcome; Pulmonary Embolism; Hemorrhage; Reperfusion
PubMed: 37767997
DOI: 10.4244/EIJ-D-23-00399 -
Stroke Oct 2021
Topics: Humans; Reperfusion; Thrombectomy
PubMed: 34470486
DOI: 10.1161/STROKEAHA.121.035815 -
Intensive Care Medicine Sep 2019To provide an update about the rapidly developing changes in the critical care management of acute ischaemic stroke patients. (Review)
Review
PURPOSE
To provide an update about the rapidly developing changes in the critical care management of acute ischaemic stroke patients.
METHODS
A narrative review was conducted in five general areas of acute ischaemic stroke management: reperfusion strategies, anesthesia for endovascular thrombectomy, intensive care unit management, intracranial complications, and ethical considerations.
RESULTS
The introduction of effective reperfusion strategies, including IV thrombolysis and endovascular thrombectomy, has revolutionized the management of acute ischaemic stroke and transformed outcomes for patients. Acute therapeutic efforts are targeted to restoring blood flow to the ischaemic penumbra before irreversible tissue injury has occurred. To optimize patient outcomes, secondary insults, such as hypotension, hyperthermia, or hyperglycaemia, that can extend the penumbral area must also be prevented or corrected. The ICU management of acute ischaemic stroke patients, therefore, focuses on the optimization of systemic physiological homeostasis, management of intracranial complications, and neurological and haemodynamic monitoring after reperfusion therapies. Meticulous blood pressure management is of central importance in improving outcomes, particularly in patients that have undergone reperfusion therapies.
CONCLUSIONS
While consensus guidelines are available to guide clinical decision making after acute ischaemic stroke, there is limited high-quality evidence for many of the recommended interventions. However, a bundle of medical, endovascular, and surgical strategies, when applied in a timely and consistent manner, can improve long-term stroke outcomes.
Topics: Brain Ischemia; Endovascular Procedures; Humans; Internal Medicine; Reperfusion; Stroke; Thrombolytic Therapy; Treatment Outcome
PubMed: 31346678
DOI: 10.1007/s00134-019-05705-y -
JAMA Neurology Dec 2020A significant proportion of acute ischemic strokes occur while patients are hospitalized. Limited contemporary data exist on the utilization rates of intravenous...
IMPORTANCE
A significant proportion of acute ischemic strokes occur while patients are hospitalized. Limited contemporary data exist on the utilization rates of intravenous thrombolysis or endovascular therapy for in-hospital stroke.
OBJECTIVE
To use a national registry to examine temporal trends in the use of intravenous and endovascular reperfusion therapies for treatment of in-hospital stroke.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective cohort study analyzed data from 267 956 patients who underwent reperfusion therapy for stroke with in-hospital or out-of-hospital onset reported in the Get With the Guidelines-Stroke national registry from January 2008 to September 2018.
EXPOSURES
In-hospital onset vs out-of-hospital onset of stroke symptoms.
MAIN OUTCOMES AND MEASURES
Temporal trends in the use of reperfusion therapy, process measures of quality, and the association between functional outcomes and key patient characteristics, comorbidities, and treatments.
RESULTS
Of 67 493 patients with in-hospital stroke onset, this study observed increased rates of vascular risk factors (standardized mean difference >10%) but no significant differences in age or sex in patients undergoing intravenous thrombolysis only (mean [interquartile range {IQR}] age, 72 [80-62] y; 53.2% female) or those undergoing endovascular therapy (mean [IQR] age, 69 [59-79] y; 49.8% female). Of these patients, 10 481 (15.5%) received intravenous thrombolysis and 2494 (3.7%) underwent endovascular therapy. Compared with 2008, in 2018 the proportion of in-hospital stroke among all stroke hospital discharges was higher (3.5% vs 2.7%; P < .001), as was use of intravenous thrombolysis (19.1% vs 9.1%; P < .001) and endovascular therapy (6.4% vs 2.5%; P < .001) in patients with in-hospital stroke, with a significant increase in endovascular therapy in mid-2015 (P < .001). Compared with patients who received intravenous thrombolysis for out-of-hospital stroke onset, those with in-hospital onset were associated with longer median (IQR) times from stroke recognition to cranial imaging (33 [18-60] vs 16 [9-26] minutes; P < .001) and to thrombolysis bolus (81 [52-125] vs 60 [45-84] minutes; P < .001). In adjusted analyses, patients with in-hospital stroke onset who were treated with intravenous thrombolysis were less likely to ambulate independently at discharge (adjusted odds ratio, 0.78; 95% CI, 0.74-0.82; P < .001) and were more likely to die or to be discharged to hospice (adjusted odds ratio, 1.39; 95% CI, 1.29-1.50; P < .001) than patients with out-of-hospital onset who also received intravenous thrombolysis treatment. Comparisons among patients treated with endovascular therapy yielded similar findings.
CONCLUSIONS AND RELEVANCE
In this cohort study, in-hospital stroke onset was increasingly reported and treated with reperfusion therapy. Compared with out-of-hospital stroke onset, in-hospital onset was associated with longer delays to reperfusion and worse functional outcomes, highlighting opportunities to further care for patients with in-hospital stroke onset.
Topics: Aged; Aged, 80 and over; Cohort Studies; Endovascular Procedures; Female; Hospitalization; Humans; Ischemic Stroke; Male; Middle Aged; Reperfusion; Retrospective Studies; Thrombolytic Therapy
PubMed: 32955582
DOI: 10.1001/jamaneurol.2020.3362 -
Cardiology Clinics Feb 2015Reperfusion, or restoration of blood flow, is an effective means of reducing disability in the setting of acute stroke. Reperfusion therapies, such as intravenous... (Review)
Review
Reperfusion, or restoration of blood flow, is an effective means of reducing disability in the setting of acute stroke. Reperfusion therapies, such as intravenous thrombolysis or endovascular and interventional procedures, fit within the existing stroke system of care. There are currently 4 devices cleared by the Food and Drug Administration for recanalization of arterial occlusion in patients with ischemic stroke. Endovascular device technology and advanced imaging technology continue to evolve with newer devices suggesting greater recanalization success. A new paradigm using advanced imaging to select patients in combination with newer devices is being tested and may lead to great improvements in care.
Topics: Adult; Aged; Aged, 80 and over; Brain; Cause of Death; Cerebral Infarction; Cooperative Behavior; Diagnostic Imaging; Disability Evaluation; Emergency Medical Services; Endovascular Procedures; Equipment Design; Humans; Interdisciplinary Communication; Middle Aged; Reperfusion; Thrombolytic Therapy; United States
PubMed: 25439334
DOI: 10.1016/j.ccl.2014.09.009 -
CNS Neuroscience & Therapeutics Apr 2024Reperfusion therapy after ischemic stroke often causes brain microvascular injury. However, the underlying mechanisms are unclear.
BACKGROUND
Reperfusion therapy after ischemic stroke often causes brain microvascular injury. However, the underlying mechanisms are unclear.
METHODS
Transcriptomic and proteomic analyses were performed on human cerebral microvascular endothelial cells following oxygen-glucose deprivation (OGD) or OGD plus recovery (OGD/R) to identify molecules and signaling pathways dysregulated by reperfusion. Major findings were further validated in a mouse model of cerebral ischemia and reperfusion.
RESULTS
Transcriptomic analysis identified 390 differentially expressed genes (DEGs) between the OGD/R and OGD group. Pathway analysis indicated that these genes were mostly associated with inflammation, including the TNF signaling pathway, TGF-β signaling pathway, cytokine-cytokine receptor interaction, NOD-like receptor signaling pathway, and NF-κB signaling pathway. Proteomic analysis identified 201 differentially expressed proteins (DEPs), which were primarily associated with extracellular matrix destruction and remodeling, impairment of endothelial transport function, and inflammatory responses. Six genes (DUSP1, JUNB, NFKBIA, NR4A1, SERPINE1, and THBS1) were upregulated by OGD/R at both the mRNA and protein levels. In mice with cerebral ischemia and reperfusion, brain TNF signaling pathway was activated by reperfusion, and inhibiting TNF-α with adalimumab significantly attenuated reperfusion-induced brain endothelial inflammation. In addition, the protein level of THBS1 was substantially upregulated upon reperfusion in brain endothelial cells and the peri-endothelial area in mice receiving cerebral ischemia.
CONCLUSION
Our study reveals the key molecular signatures of brain endothelial reperfusion injury and provides potential therapeutic targets for the treatment of brain microvascular injury after reperfusion therapy in ischemic stroke.
Topics: Mice; Humans; Animals; Endothelial Cells; Proteomics; Brain; Brain Ischemia; Reperfusion Injury; Oxygen; Brain Injuries; Inflammation; Reperfusion; Gene Expression Profiling; Ischemic Stroke; Glucose
PubMed: 37789643
DOI: 10.1111/cns.14483 -
Stroke Mar 2021The mechanisms linking systemic inflammation to poor outcome in ischemic stroke are not fully understood. The authors investigated if peripheral inflammation following...
BACKGROUND AND PURPOSE
The mechanisms linking systemic inflammation to poor outcome in ischemic stroke are not fully understood. The authors investigated if peripheral inflammation following reperfusion therapy leads to an increase in cerebral edema (CED), thus hindering the clinical recovery.
METHODS
We designed a single-center study conducted at Centro Hospitalar Universitário São João between 2017 and 2019. Inclusion criteria were being adult, having an anterior circulation acute ischemic stroke, and receiving reperfusion therapy. Neutrophil-to-lymphocyte, platelet-to-lymphocyte ratios, and the systemic inflammatory response syndrome criteria were determined. The presence and grade of CED were evaluated on the computed tomography performed 24 hours following event. The clinical outcomes included early neurological deterioration and functional dependence at 90 days. Adjusted odds ratio and 95% CI were obtained by ordinal and logistic regression models. Optimal cutoff values were defined using receiver operating characteristic analysis in the training cohort and validated in an independent data set.
RESULTS
Five hundred fifty-three patients were included. Neutrophil-to-lymphocyte increased with higher degrees of CED at 24 hours (adjusted odds ratio, 1.34 [1.09-1.68], <0.01) and was associated with early neurological deterioration (adjusted odds ratio, 1.30 [1.04-1.63], <0.05) and poor functional status at 90 days (adjusted odds ratio, 1.79 [1.28-2.48], <0.01). Platelet-to-lymphocyte was not associated with the outcomes. Systemic inflammatory response syndrome was related to CED due to altered white blood cell counts. Neutrophil-to-lymphocyte was the best predictor with an area under the curve around 0.7. Neutrophil-to-lymphocyte ≥7 had and accuracy, sensitivity, and specificity around 60%.
CONCLUSIONS
Increased systemic inflammation is linked to the severity of CED early after reperfusion therapy in stroke. Easily obtained inflammatory markers convey early warning alerts for patients at risk of severe neurological complications with an impact on long-term functional outcome. CED quantification should be included as an end point in proof-of-concept trials in immunomodulation in stroke.
Topics: Adolescent; Adult; Aged; Blood Platelets; Brain Edema; Cell Count; Edema; Humans; Inflammation; Lymphocyte Count; Lymphocytes; Middle Aged; Neutrophils; Odds Ratio; Prospective Studies; ROC Curve; Regression Analysis; Reperfusion; Retrospective Studies; Stroke; Thrombectomy; Tomography, X-Ray Computed; Treatment Outcome; Young Adult
PubMed: 33517702
DOI: 10.1161/STROKEAHA.120.032130 -
Acta Neurologica Scandinavica Apr 2021Computed tomography perfusion (CTP) imaging could be useful in guiding reperfusion therapy or patient selection in acute ischemic stroke (AIS) patients. The aim of the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Computed tomography perfusion (CTP) imaging could be useful in guiding reperfusion therapy or patient selection in acute ischemic stroke (AIS) patients. The aim of the current study was to determine the efficacy of the CTP-guided reperfusion therapy in AIS by performing a systematic review and meta-analysis.
METHODS
Medline/PubMed, Embase, and the Cochrane library were searched using the terms: "CT perfusion", "acute stroke" and "reperfusion therapy". The following studies were included: (a) studies reporting original data; (b) patients aged 18 years or above; (c) patients diagnosed with anterior circulation AIS; and (d) studies with good methodological design.
RESULTS
Twenty-two studies were finally included in the metanalysis with a total of 5, 687 patients. CTP-guided reperfusion therapy was associated with increased odds of good functional outcome without significant difference in safety profile.
CONCLUSIONS
CTP-guided reperfusion therapy improved functional outcomes in AIS, with increased benefits to patients treated with endovascular thrombectomy.
Topics: Adolescent; Aged; Brain Ischemia; Female; Humans; Ischemic Stroke; Male; Middle Aged; Randomized Controlled Trials as Topic; Reperfusion; Thrombectomy; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 33188539
DOI: 10.1111/ane.13374