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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 -
Critical Care Nursing Clinics of North... Mar 2020It is unpredictable which stroke survivors will experience a seizure following a stroke. Stroke is a major cause of seizures. Critical care nurses need to know the risk... (Review)
Review
It is unpredictable which stroke survivors will experience a seizure following a stroke. Stroke is a major cause of seizures. Critical care nurses need to know the risk factors, type of stroke at risk, stroke location, and severity for the poststroke patient who is at risk for an early or late seizure. Poststroke seizures require appropriate nursing assessments, management, and support.
Topics: Brain; Critical Care Nursing; Electroencephalography; Epilepsy; Humans; Risk Factors; Seizures; Stroke
PubMed: 32014163
DOI: 10.1016/j.cnc.2019.11.006 -
Practical Neurology Apr 2023Sickle cell disease (SCD) is the most common type of hereditary anaemia and genetic disorder worldwide. Cerebrovascular disease is one of its most devastating...
Sickle cell disease (SCD) is the most common type of hereditary anaemia and genetic disorder worldwide. Cerebrovascular disease is one of its most devastating complications, with consequent increased morbidity and mortality. Current guidelines suggest that children and adults with SCD who develop acute ischaemic stroke should be transfused without delay. Those with acute ischaemic stroke aged over 18 years who present within 4.5 hours of symptom onset should be considered for intravenous thrombolysis; older patients with conventional vascular risk factors are the most likely to benefit. Endovascular thrombectomy should be considered carefully in adults with SCD as there are few data to guide how the prevalence of cerebral vasculopathy may confound the expected benefits or risks of intervention. We present a practical approach to cerebrovascular disease in sickle cell patients based on the available evidence and our experience.
Topics: Child; Adult; Humans; Middle Aged; Stroke; Brain Ischemia; Anemia, Sickle Cell; Ischemic Stroke; Risk Factors
PubMed: 36123118
DOI: 10.1136/pn-2022-003440 -
Journal of Vascular Surgery May 2024Cryptogenic stroke represents a type of ischemic stroke with an unknown origin, presenting a significant challenge in both stroke management and prevention. According to... (Review)
Review
OBJECTIVES
Cryptogenic stroke represents a type of ischemic stroke with an unknown origin, presenting a significant challenge in both stroke management and prevention. According to the Trial of Org 10,172 in Acute Stroke Treatment criteria, a stroke is categorized as being caused by large artery atherosclerosis only when there is >50% luminal narrowing of the ipsilateral internal carotid artery. However, nonstenosing carotid artery plaques can be an underlying cause of ischemic stroke. Indeed, emerging evidence documents that some features of plaque vulnerability may act as an independent risk factor, regardless of the degree of stenosis, in precipitating cerebrovascular events. This review, drawing from an array of imaging-based studies, explores the predictive values of carotid imaging modalities in the detection of nonstenosing carotid plaque (<50%), that could be the cause of a cerebrovascular event when some features of vulnerability are present.
METHODS
Google Scholar, Scopus, and PubMed were searched for articles on cryptogenic stroke and those reporting the association between cryptogenic stroke and imaging features of carotid plaque vulnerability.
RESULTS
Despite extensive diagnostic evaluations, the etiology of a considerable proportion of strokes remains undetermined, contributing to the recurrence rate and persistent morbidity in affected individuals. Advances in imaging modalities, such as magnetic resonance imaging, computed tomography scans, and ultrasound examination, facilitate more accurate detection of nonstenosing carotid artery plaque and allow better stratification of stroke risk, leading to a more tailored treatment strategy.
CONCLUSIONS
Early detection of nonstenosing carotid plaque with features of vulnerability through carotid imaging techniques impacts the clinical management of cryptogenic stroke, resulting in refined stroke subtype classification and improved patient management. Additional research is required to validate these findings and recommend the integration of these state-of-the-art imaging methodologies into standard diagnostic protocols to improve stroke management and prevention.
Topics: Humans; Carotid Stenosis; Stroke; Carotid Arteries; Ischemic Stroke; Plaque, Atherosclerotic
PubMed: 38190926
DOI: 10.1016/j.jvs.2024.01.004 -
Journal of Stroke and Cerebrovascular... Jun 2023Stroke patients and family members should receive stroke education including recognition of stroke symptoms and prompt activation of emergency medical services (EMS)....
BACKGROUND
Stroke patients and family members should receive stroke education including recognition of stroke symptoms and prompt activation of emergency medical services (EMS). The impact of this education is unclear. We aimed to measure the associations between EMS use and timing of hospital arrival and first-ever and recurrent strokes as a proxy for stroke education.
METHODS
The study analyzed data from validated strokes identified by the Brain Attack Surveillance in Corpus Christi (BASIC) project between 1/1/2000-1/1/2020. We analyzed 5,617 first-ever strokes, 259 instances of recurrent stroke within 1 year of the first (early recurrence), and 451 recurrent strokes over 1 year from the first (late recurrence). Following imputation, associations of both EMS arrival (available starting late 2011) and early arrival (< 3 hours) with first-ever versus recurrent stroke (early and late) were assessed with logistic models, accounting for the clustering of multiple strokes per participant with generalized estimating equations. Full model covariates included stroke type, initial stroke severity, marital status, race/ethnicity, gender, age, insurance, education, and EMS use (early arrival model only).
RESULTS
Compared to first-ever stroke, there were significantly higher unadjusted odds of arrival by EMS for the late recurrence group (late recurrence OR = 1.54, 95% CI = 1.18-1.99; early arrival OR = 1.24, 95% CI = 0.87-1.76). The association for late recurrence remained significant after adjustment (aOR = 1.46, 95% CI = 1.09-1.95). The pre-2010 unadjusted odds of early arrival were non-significant for both early and late recurrence groups (late recurrence OR = 1.05, CI = 0.70-1.56; early recurrence OR = 0.85, CI = 0.54-1.33), while late recurrence was associated with early arrival after 2010 (OR = 1.32, 95% CI = 1.03-1.69). After full adjustment, it was no longer significant (aOR = 1.25, 95% CI = 0.96-1.62). Higher initial stroke severity, married status, and EMS use were associated with higher odds of early arrival, while African Americans (AAs) had lower odds than non-Hispanic Whites (NHWs). However, AAs did have higher odds of EMS use relative to NHWs. Those who were married and living together had borderline significant lower odds of EMS use compared to those who were not.
CONCLUSIONS
Our study examines the association of repeat stroke on early arrival and EMS use as a surrogate for adequate stroke education. Recurrence at least one year after the first stroke was associated with higher EMS usage, but there was not enough evidence to establish a relationship with early arrival after accounting for EMS usage and possible confounders. By examining subsets, we can identify groups that would benefit from targeted education. For example, younger, non-AA patients with smaller strokes would benefit from more education on EMS use and African American patients would benefit from education related to faster recognition or urgency of presentation.
Topics: Humans; Stroke; Emergency Medical Services; Cerebral Infarction; Ethnicity; White
PubMed: 37037176
DOI: 10.1016/j.jstrokecerebrovasdis.2023.107069 -
International Journal of Environmental... Sep 2021Stroke (i.e., cerebrovascular accident) affects one in 10,000 people between the ages of 14 and 45; however, very little is known about the frequency and type of stroke... (Review)
Review
Stroke (i.e., cerebrovascular accident) affects one in 10,000 people between the ages of 14 and 45; however, very little is known about the frequency and type of stroke that occurs in athletes. The risk of injury to the neurovascular structures may depend on the type of sport involvement, although, sport-specific incidence rates are not known. Therefore, the goal of our scoping review was to provide some guidance to better inform the development of a context-fit stroke model by summarizing studies on a broad research topic related to stroke or cerebrovascular accident in sport based on a strict athlete definition. We used the guidance of Arksey and O'Malley's five-stage-process for a scoping review. Databases included MEDLINE(R) Epub Ahead of Print, In-Process & Other Non- Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), and Embase (OVID databases); CINAHL Plus with Full Text, SportDiscus with Full Text (Ebsco databases); and Scopus. Publication dates were from 1979-2020 across nine different countries resulting in 39 individual cases of stroke with an athlete age range of 14-56 years (95% male). The major inciting event(s) prior to stroke onset were headaches (38.4%), head trauma (30.7%), and neck injury and/or vertebral artery dissection (20.5%). Several sporting activities were represented with American football as the most prevalent (30.7%). In summary, we found that sports with an aspect of impact, collision, or microtrauma can lead to subsequent stroke. These sport-related traumatic events were often difficult to diagnose because of the longer interval before ischemia occurred. Therefore, health care providers should be particularly attuned to the possibility of stroke when evaluating athletes presenting with or without neurological deficit.
Topics: Adolescent; Adult; Athletes; Female; Football; Humans; Male; Middle Aged; Stroke; Young Adult
PubMed: 34639349
DOI: 10.3390/ijerph181910047 -
Continuum (Minneapolis, Minn.) Apr 2020This article reviews the evidence base and recommendations for medical management for secondary stroke prevention. (Review)
Review
PURPOSE OF REVIEW
This article reviews the evidence base and recommendations for medical management for secondary stroke prevention.
RECENT FINDINGS
Recent developments for secondary stroke prevention include evidence to support the use of short-term dual antiplatelet therapy after minor stroke and transient ischemic attack, direct oral anticoagulants for nonvalvular atrial fibrillation, reversal agents for direct oral anticoagulant-associated hemorrhage, and aspirin rather than presumptive anticoagulation with a direct oral anticoagulant for embolic stroke of undetermined source.
SUMMARY
Most strokes are preventable. The mainstays of medical management for secondary stroke prevention include antihypertensive therapy; antithrombotic therapy, with antiplatelet agents for most stroke subtypes or anticoagulants such as warfarin or a direct oral anticoagulant for cardioembolic stroke specifically; cholesterol-lowering therapy, principally with statins, but with potential roles for ezetimibe or proprotein convertase subtilisin/kexin type 9 inhibitors in selected patients; and glycemic control to prevent microvascular complications from diabetes mellitus or pioglitazone in selected patients with insulin resistance but not diabetes mellitus.
Topics: Anticholesteremic Agents; Anticoagulants; Antihypertensive Agents; Fibrinolytic Agents; Humans; Hypoglycemic Agents; Platelet Aggregation Inhibitors; Secondary Prevention; Stroke
PubMed: 32224760
DOI: 10.1212/CON.0000000000000849