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Critical Care Clinics Jan 2023This article reviews the care of patients with ischemic stroke in the intensive care unit, including early general critical care interventions for airway control blood... (Review)
Review
This article reviews the care of patients with ischemic stroke in the intensive care unit, including early general critical care interventions for airway control blood pressure goals according to the type of acute stroke treatment, poststroke cerebral edema management, hemorrhagic conversion in ischemic stroke, fibrinolytic reversal, and management of carotid endarterectomy and infective endocarditis. The importance of preventing common intensive care complications is discussed, including aspiration pneumonia, deep venous thrombosis, urinary tract infections, cardiac arrhythmias, and hyperglycemia.
Topics: Humans; Brain Ischemia; Ischemic Stroke; Stroke; Thrombolytic Therapy; Critical Care
PubMed: 36333037
DOI: 10.1016/j.ccc.2022.07.005 -
Journal of Medicine and Life Jun 2023Watershed strokes have been described previously as ischemic strokes located in vulnerable border zones between brain tissue supplied by the anterior, posterior, and... (Review)
Review
Watershed strokes have been described previously as ischemic strokes located in vulnerable border zones between brain tissue supplied by the anterior, posterior, and middle cerebral arteries in the distal junction between two non-anastomotic arterial territories. Ischemic strokes in border zones are well-recognized entities and well-described in terms of imaging features, but the pathophysiological mechanism of brain injury production is not fully defined. Border zone ischemia is caused by cerebral hypoperfusion through decreased cerebral blood flow and arterial embolism in unstable atheroma plaque. It is often difficult to say which mechanisms are fully responsible for producing cerebral ischemic lesions. This review aimed to highlight the imaging aspect of watershed strokes and to correlate the clinical characteristics of this type of stroke with the diagnostic algorithm for optimal therapeutic management. Neurologists should promptly recognize this type of stroke and investigate its etiology in the shortest possible time.
Topics: Humans; Stroke; Ischemic Stroke; Middle Cerebral Artery
PubMed: 37675172
DOI: 10.25122/jml-2023-0127 -
NeoReviews Mar 2021Perinatal stroke is a focal vascular brain injury that occurs from the fetal period to 28 days of postnatal age. With an overall incidence of up to 1 in 1,000 live... (Review)
Review
Perinatal stroke is a focal vascular brain injury that occurs from the fetal period to 28 days of postnatal age. With an overall incidence of up to 1 in 1,000 live births, the most focused lifetime risk for stroke occurs near birth. Perinatal stroke can be classified by the timing of diagnosis, vessel involvement, and type of injury. Timing of diagnosis may be in the acute neonatal period or retrospectively after a period of normal development, followed by abnormal neurologic findings, with the injury presumed to have occurred around the time of birth. Strokes may be arterial or venous, ischemic, and/or hemorrhagic. Within these classifications, 6 perinatal stroke diseases are recognizable, based on clinical and radiographic features. Morbidity is high in perinatal stroke, because it accounts for most cases of hemiparetic cerebral palsy, with disability lasting a lifetime. Additional complications include disorders of sensation and vision, language delays, cognitive and learning deficits, epilepsy, and mental health consequences that affect the entire family. Advances in neonatal neurocritical care may afford opportunity to minimize brain injury and improve outcomes. In the chronic timeframe, progress made in neuroimaging and brain mapping is revealing the developmental plasticity that occurs, informing new avenues for neurorehabilitation. This review will summarize the diagnosis and management of each perinatal stroke disease, highlighting their similarities and distinctions and emphasizing a patient- and family-centered approach to management.
Topics: Female; Humans; Incidence; Infant, Newborn; Infant, Newborn, Diseases; Pregnancy; Retrospective Studies; Stroke
PubMed: 33649089
DOI: 10.1542/neo.22-3-e163 -
European Journal of Neurology Jan 2018There are about 25.7 million stroke survivors worldwide. Ischaemic stroke remains the most common type of stroke. Numerous modifiable risk factors have been identified,... (Review)
Review
There are about 25.7 million stroke survivors worldwide. Ischaemic stroke remains the most common type of stroke. Numerous modifiable risk factors have been identified, including behaviors such as cigarette smoking and sedentary lifestyle and treatable medical comorbidities such as hypertension, hyperlipidemia and atrial fibrillation. Once considered irreversible, acute ischaemic stroke is now amenable to acute medical and endovascular therapies to reduce infarct volume. Many advances are expected in the years to come, particularly in the areas of prevention and recovery.
Topics: Brain Ischemia; Humans; Hypertension; Risk Factors; Stroke; Thrombectomy; Thrombolytic Therapy
PubMed: 28800170
DOI: 10.1111/ene.13409 -
Stroke Apr 2024Small, randomized trials of patients with cervical artery dissection showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare... (Observational Study)
Observational Study
BACKGROUND
Small, randomized trials of patients with cervical artery dissection showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare outcomes in patients with cervical artery dissection treated with antiplatelets versus anticoagulation.
METHODS
This is a multicenter observational retrospective international study (16 countries, 63 sites) that included patients with cervical artery dissection without major trauma. The exposure was antithrombotic treatment type (anticoagulation versus antiplatelets), and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with inverse probability of treatment weighting to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an as-treated crossover approach and only included outcomes occurring with the above treatments.
RESULTS
The study included 3636 patients (402 [11.1%] received exclusively anticoagulation and 2453 [67.5%] received exclusively antiplatelets). By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with inverse probability of treatment weighting, compared with antiplatelet therapy, anticoagulation was associated with a nonsignificantly lower risk of subsequent ischemic stroke by day 30 (adjusted hazard ratio [HR], 0.71 [95% CI, 0.45-1.12]; =0.145) and by day 180 (adjusted HR, 0.80 [95% CI, 0.28-2.24]; =0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR, 1.39 [95% CI, 0.35-5.45]; =0.637) but was by day 180 (adjusted HR, 5.56 [95% CI, 1.53-20.13]; =0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR, 0.40 [95% CI, 0.18-0.88]; =0.009).
CONCLUSIONS
Our study does not rule out the benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings.
Topics: Humans; Platelet Aggregation Inhibitors; Anticoagulants; Fibrinolytic Agents; Retrospective Studies; Carotid Artery, Internal, Dissection; Stroke; Hemorrhage; Ischemic Stroke; Aortic Dissection; Arteries; Atrial Fibrillation; Treatment Outcome
PubMed: 38335240
DOI: 10.1161/STROKEAHA.123.045731 -
Restorative Neurology and Neuroscience 2020Previous studies have shown that hyperbaric oxygen therapy (HBOT) can improve the motor functions and memory of post-stroke patients in the chronic stage.
BACKGROUND
Previous studies have shown that hyperbaric oxygen therapy (HBOT) can improve the motor functions and memory of post-stroke patients in the chronic stage.
OBJECTIVE
The aim of this study is to evaluate the effects of HBOT on overall cognitive functions of post-stroke patients in the chronic stage. The nature, type and location of the stroke were investigated as possible modifiers.
METHODS
A retrospective analysis was conducted on patients who were treated with HBOT for chronic stroke (>3 months) between 2008-2018. Participants were treated in a multi-place hyperbaric chamber with the following protocols: 40 to 60 daily sessions, 5 days per week, each session included 90 min of 100% oxygen at 2 ATA with 5 min air brakes every 20 minutes. Clinically significant improvements (CSI) were defined as > 0.5 standard deviation (SD).
RESULTS
The study included 162 patients (75.3% males) with a mean age of 60.75±12.91. Of them, 77(47.53%) had cortical strokes, 87(53.7%) strokes were located in the left hemisphere and 121 suffered ischemic strokes (74.6%).HBOT induced a significant increase in all the cognitive function domains (p < 0.05), with 86% of the stroke victims achieving CSI. There were no significant differences post-HBOT of cortical strokes compared to sub-cortical strokes (p > 0.05). Hemorrhagic strokes had a significantly higher improvement in information processing speed post-HBOT (p < 0.05). Left hemisphere strokes had a higher increase in the motor domain (p < 0.05). In all cognitive domains, the baseline cognitive function was a significant predictor of CSI (p < 0.05), while stroke type, location and side were not significant predictors.
CONCLUSIONS
HBOT induces significant improvements in all cognitive domains even in the late chronic stage. The selection of post-stroke patients for HBOT should be based on functional analysis and baseline cognitive scores rather than the stroke type, location or side of lesion.
Topics: Aged; Aged, 80 and over; Brain; Cognition; Female; Humans; Hyperbaric Oxygenation; Male; Memory; Middle Aged; Oxygen; Retrospective Studies; Stroke
PubMed: 31985478
DOI: 10.3233/RNN-190959 -
Der Anaesthesist Jan 2021Perioperative stroke is defined as an ischemic cerebrovascular event that occurs during or within 30 days after surgery and is associated with an increased... (Review)
Review
Perioperative stroke is defined as an ischemic cerebrovascular event that occurs during or within 30 days after surgery and is associated with an increased perioperative risk of morbidity and mortality. Depending on the type of surgery stroke is diagnosed in up to 11% of all patients in the perioperative period. Patients with a history of ischemic stroke or transitory ischemic attack have an increased risk for perioperative stroke. Therefore, a critical assessment of indications and the timing of surgery are crucial to prevent recurring stroke in this patient population. Importantly, individualized blood pressure management is essential for optimization of cerebral perfusion during the perioperative period.This article provides a summary of the epidemiology, risk factors, and etiology of perioperative stroke. Moreover, possible preventive strategies relevant for the anesthesiologist are reviewed.
Topics: Humans; Ischemic Attack, Transient; Perioperative Period; Postoperative Complications; Risk Factors; Stroke
PubMed: 32749502
DOI: 10.1007/s00101-020-00823-5 -
The Lancet. Global Health Apr 2020Stroke is a leading cause of death and disability worldwide. Despite considerable improvements in diagnosis and treatment, little is known about the short-term and...
BACKGROUND
Stroke is a leading cause of death and disability worldwide. Despite considerable improvements in diagnosis and treatment, little is known about the short-term and long-term prognosis after a first stroke in low-income and middle-income countries, including China. We aimed to assess the short-term and long-term risk of recurrent stroke and mortality after a first stroke for each of the major pathological stroke types.
METHODS
This population-based cohort study included adults aged 35-74 years without disability who were recruited to the China Kadoorie Biobank (CKB). A baseline survey was conducted in ten geographical areas (five urban, five rural) in China, and participants had clinical measurements recorded. Participants were followed up by monitoring death registries and by electronic linkage to health registries and health insurance claims databases, with follow-up until Jan 1, 2017. Participants were excluded from analyses if they had a previous history of stroke, transient ischaemic attack, or ischaemic heart disease at baseline. All incidences of fatal and non-fatal stroke during the study period were recorded by type (ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and unspecified type). Primary outcome measures were 28-day mortality, recurrent stroke, major vascular events (recurrent stroke, myocardial infarction, or vascular death), vascular mortality, and all-cause mortality.
FINDINGS
Of 512 715 individuals in the CKB, 489 586 participants without previous ischaemic heart disease and stroke at recruitment were included, of whom 45 732 (42 073 [92%] confirmed by brain imaging) had a stroke during the study period. The mean age was 59·3 years (SD 9·8) for participants who had a stroke (54% women) and 50·8 years (10·3) for participants with no stroke (60% women). 36 588 (80%) of the incident cases of stroke were ischaemic stroke, 7440 (16%) were intracerebral haemorrhage, 702 (2%) were subarachnoid haemorrhage, and 1002 (2%) were an unspecified stroke type. 28-day mortality was 3% (95% CI 3-4) for ischaemic stroke, 47% (46-48)for intracerebral haemorrhage, 19% (17-22; 52% for rural areas and 32% for urban areas) subarachnoid haemorrhage, and 24% (22-27) for unspecified stroke. Among participants who survived stroke at 28 days, 41% (41-42) had recurrent stroke at 5 years (ischaemic stroke 41% [41-42], intracerebral haemorrhage 44% [42-46], subarachnoid haemorrhage 22% [18-27], unspecified stroke type 40% [35-44]) and mortality at 5 years was 17% ([17-18] ischaemic stroke 16% [15-16], intracerebral haemorrhage 28% [26-29], subarachnoid haemorrhage 16% [12-20], unspecified stroke type 15% [12-19]). After a first ischaemic stroke, 91% of recurrent strokes were also ischaemic stroke; after an intracerebral haemorrhage, 56% of recurrent strokes were intracerebral haemorrhage, and 41% of recurrent strokes were ischaemic stroke.
INTERPRETATION
After a first stroke, the risk of recurrence or death within 5 years was high among this population of Chinese adults. Urgent improvements to secondary prevention of stroke in China are needed to reduce these risks.
FUNDING
Wellcome Trust, Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, Chinese Ministry of Science and Technology, National Natural Science Foundation of China.
COPYRIGHT
© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.
Topics: Adult; Aged; China; Cohort Studies; Female; Humans; Incidence; Male; Middle Aged; Recurrence; Risk Assessment; Stroke
PubMed: 32199124
DOI: 10.1016/S2214-109X(20)30069-3 -
Current Neurology and Neuroscience... Jul 2022We reviewed lipid-modifying therapies and the risk of stroke and other cerebrovascular outcomes, with a focus on newer therapies. (Review)
Review
PURPOSE OF REVIEW
We reviewed lipid-modifying therapies and the risk of stroke and other cerebrovascular outcomes, with a focus on newer therapies.
RECENT FINDINGS
Statins and ezetimibe reduce ischemic stroke risk without increasing hemorrhagic stroke risk. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors similarly reduce ischemic stroke risk in statin-treated patients with atherosclerosis without increasing hemorrhagic stroke, even with very low achieved low-density lipoprotein cholesterol levels. Icosapent ethyl reduces the risk of total and first ischemic stroke in patients with established cardiovascular disease or diabetes mellitus. Clinical outcome trials are underway for newer lipid-modifying agents, including inclisiran, bempedoic acid, and pemafibrate. New biologic agents including evinacumab, pelacarsen, olpasiran, and SLN360 are also discussed. In addition to statins and ezetimibe, PCSK9 inhibitors and icosapent ethyl reduce the risk of ischemic stroke without increasing the risk of hemorrhagic stroke. These therapies dramatically expand options for reducing stroke in high-risk settings.
Topics: Anticholesteremic Agents; Cardiovascular Diseases; Ezetimibe; Hemorrhagic Stroke; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ischemic Stroke; Lipids; Proprotein Convertase 9; Stroke
PubMed: 35554824
DOI: 10.1007/s11910-022-01197-4 -
Stroke and Vascular Neurology Feb 2024Recombinant human TNK tissue-type plasminogen activator (rhTNK-tPA) was not inferior to alteplase for ischaemic stroke within 4.5 hours. Our study aimed to investigate... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND AND PURPOSE
Recombinant human TNK tissue-type plasminogen activator (rhTNK-tPA) was not inferior to alteplase for ischaemic stroke within 4.5 hours. Our study aimed to investigate the efficacy and safety of rhTNK-tPA in patients who had an ischaemic stroke due to large vessel occlusion (LVO) of anterior circulation beyond 4.5 hours.
METHODS AND DESIGN
Tenecteplase Reperfusion Therapy in Acute Ischaemic Cerebrovascular Events-III (TRACE III) is a multicentre, prospective, randomised, open-label, blind endpoint, controlled clinical trial. Patients who had an ischaemic stroke due to anterior circulation LVO (internal carotid artery, middle cerebral artery M1 and M2 segments) within 4.5-24 hours from last known well (including wake-up stroke and no witness stroke) and with salvageable tissue (ischaemic core volume <70 mL, mismatch ratio ≥1.8 and mismatch volume ≥15 mL) based on CT perfusion or MRI perfusion-weighted imaging (PWI) were included and randomised to rhTNK-tPA 0.25 mg/kg (single bolus) to a maximum of 25 mg or standard medical therapy. Specially, we will exclude patients who are intended for direct thrombectomy. All will be followed up for 90 days.
STUDY OUTCOMES
Primary efficacy outcome is modified Rankin Scale (mRS) score ≤1 at 90 days. Secondary efficacy outcomes include ordinal distribution of mRS at 90 days, major neurological improvement defined by a decrease ≥8 points compared with the initial deficit or a score ≤1 on the National Institutes of Health Stroke Scale (NIHSS) at 72 hours, mRS score ≤2 at 90 days, the rate of improvement on Tmax >6 s at 24 hours and NIHSS score change from baseline at 7 days. Safety outcomes are symptomatic intracerebral haemorrhage within 36 hours and mortality at 90 days.
DISCUSSION
TRACE III will provide evidence for the efficacy and safety of rhTNK-tPA in patients who had an ischaemic strokes due to anterior circulation LVO beyond 4.5 hours.
TRIAL REGISTRATION NUMBER
NCT05141305.
Topics: United States; Humans; Tenecteplase; Fibrinolytic Agents; Stroke; Brain Ischemia; Prospective Studies; Treatment Outcome; Ischemic Stroke; Reperfusion
PubMed: 37247876
DOI: 10.1136/svn-2023-002310