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Stroke Nov 2015Stroke affects ≈700,000 patients annually. Recent randomized controlled trials comparing endovascular thrombectomy (ET) with medical therapy, including intravenous... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND PURPOSE
Stroke affects ≈700,000 patients annually. Recent randomized controlled trials comparing endovascular thrombectomy (ET) with medical therapy, including intravenous thrombolysis (IVT) with tissue-type plasminogen activator, have shown effectiveness of ET for some stroke patients. The study objective is to evaluate the effect of ET on good outcome in stroke patients.
METHODS
We searched PubMed, Embase, Web of Science, SCOPUS, ClinicalTrials.gov, and Cochrane databases to identify original research publications between 1996 and 2015 that (1) reported clinical outcomes in patients for stroke at 90 days with the modified Rankin Scale; (2) included at least 10 patients per group; (3) compared outcome with a control arm, and (4) included anterior circulation strokes in each arm. Two authors reviewed articles for inclusion independently.
RESULTS
Nine of 23 809 studies met inclusion criteria. In primary analysis, ET was associated with increased odds for good outcome (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.20-2.54). In secondary analysis, younger patients (OR, 1.85; 95% CI, 1.50-2.28), older patients (OR, 1.93; 95% CI, 1.10-3.37), patients receiving intravenous thrombolysis (OR, 1.83; 95% CI, 1.46-2.31), patients with worse strokes (OR, 2.23; 95% CI, 1.56-3.18), and patients with more moderate strokes (OR, 1.72; 95% CI, 1.36-2.18) had increased odds for good outcome. Symptomatic intracranial hemorrhage and mortality were similar between ET and control patients. No evidence of publication bias was seen.
CONCLUSIONS
ET improves good outcomes after anterior circulation stroke. ET should be strongly considered for all patients presenting within 6 hours of onset with a stroke affecting a proximal, anterior circulation vessel without a contraindication to ET.
Topics: Brain Ischemia; Combined Modality Therapy; Endovascular Procedures; Humans; Stroke; Thrombectomy; Thrombolytic Therapy; Treatment Outcome
PubMed: 26396032
DOI: 10.1161/STROKEAHA.115.009847 -
Stroke Sep 2015Diabetes mellitus is a high-risk factor for ischemic stroke. Diabetic stroke patients suffer worse outcomes, poor long-term recovery, risk of recurrent strokes, and...
BACKGROUND AND PURPOSE
Diabetes mellitus is a high-risk factor for ischemic stroke. Diabetic stroke patients suffer worse outcomes, poor long-term recovery, risk of recurrent strokes, and extensive vascular damage. We investigated the neurorestorative effects and the underlying mechanisms of stroke treatment with human umbilical cord blood cells (HUCBCs) in type 2 diabetes mellitus (T2DM) rats.
METHODS
Adult male T2DM rats were subjected to 2 hours of middle cerebral artery occlusion (MCAo). Three days after MCAo, rats were treated via tail-vein injection with (1) PBS and (2) HUCBCs (5×10(6)), n=10 per group.
RESULTS
HUCBC stroke treatment initiated 3 days after MCAo in T2DM rats did not significantly decrease blood-brain barrier leakage (P=0.1) and lesion volume (P=0.078), but significantly improved long-term functional outcome and decreased brain hemorrhage (P<0.05) when compared with the PBS-treated T2DM MCAo control group. HUCBC treatment significantly promoted white matter remodeling as indicated by increased expression of Bielschowsky silver (axons marker), Luxol fast blue (myelin marker), SMI-31 (neurofilament), and Synaptophysin in the ischemic border zone. HUCBC promoted vascular remodeling and significantly increased arterial and vascular density. HUCBC treatment of stroke in T2DM rats significantly increased M2 macrophage polarization (increased M2 macrophage, CD163and CD 206; decreased M1 macrophage, ED1 and inducible nitric oxide synthase expression) in the ischemic brain compared with PBS-treated T2DM MCAo controls (P<0.05). HUCBC also significantly decreased proinflammatory factors, that is, matrix metalloproteinase 9, receptor for advanced glycation end products and toll-like receptor 4 expression in the ischemic brain.
CONCLUSIONS
HUCBC treatment initiated 3 days after stroke significantly increased white matter and vascular remodeling in the ischemic brain as well as decreased neuroinflammatory factor expression in the ischemic brain in T2DM rats and promoted M2 macrophage polarization. HUCBC reduction of neuroinflammation and increased vascular and white matter axonal remodeling may contribute to the HUCBC-induced beneficial effects in T2DM stroke rats.
Topics: Animals; Brain Ischemia; Cord Blood Stem Cell Transplantation; Diabetes Mellitus, Type 2; Disease Models, Animal; Humans; Infarction, Middle Cerebral Artery; Male; Rats; Rats, Wistar; Stroke
PubMed: 26243222
DOI: 10.1161/STROKEAHA.115.009870 -
Journal of the American College of... May 2021Stroke is one of the most common and potentially disabling complications of infective endocarditis (IE). However, scarce data exist about stroke complicating IE after... (Observational Study)
Observational Study
BACKGROUND
Stroke is one of the most common and potentially disabling complications of infective endocarditis (IE). However, scarce data exist about stroke complicating IE after transcatheter aortic valve replacement (TAVR).
OBJECTIVES
The purpose of this study was to determine the incidence, risk factors, clinical characteristics, management, and outcomes of patients with definite IE after TAVR complicated by stroke during index IE hospitalization.
METHODS
Data from the Infectious Endocarditis after TAVR International Registry (including 569 patients who developed definite IE following TAVR from 59 centers in 11 countries) was analyzed. Patients were divided into two groups according to stroke occurrence during IE admission (stroke [S-IE] vs. no stroke [NS-IE]).
RESULTS
A total of 57 (10%) patients had a stroke during IE hospitalization, with no differences in causative microorganism between groups. S-IE patients exhibited higher rates of acute renal failure, systemic embolization, and persistent bacteremia (p < 0.05 for all). Previous stroke before IE, residual aortic regurgitation ≥moderate after TAVR, balloon-expandable valves, IE within 30 days after TAVR, and vegetation size >8 mm were associated with a higher risk of stroke during the index IE hospitalization (p < 0.05 for all). Stroke rate in patients with no risk factors was 3.1% and increased up to 60% in the presence of >3 risk factors. S-IE patients had higher rates of in-hospital mortality (54.4% vs. 28.7%; p < 0.001) and overall mortality at 1 year (66.3% vs. 45.6%; p < 0.001). Surgical treatment was not associated with improved outcomes in S-IE patients (in-hospital mortality: 46.2% in surgical vs. 58.1% in no surgical treatment; p = 0.47).
CONCLUSIONS
Stroke occurred in 1 of 10 patients with IE post-TAVR. A history of stroke, short time between TAVR and IE, vegetation size, valve prosthesis type, and residual aortic regurgitation determined an increased risk. The occurrence of stroke was associated with increased in-hospital and 1-year mortality rates, and surgical treatment failed to improve clinical outcomes.
Topics: Aged; Aged, 80 and over; Endocarditis, Bacterial; Female; Humans; Incidence; Male; Postoperative Complications; Retrospective Studies; Risk Factors; Stroke; Transcatheter Aortic Valve Replacement
PubMed: 33958124
DOI: 10.1016/j.jacc.2021.03.233 -
The American Journal of Cardiology Aug 2007Despite the substantial evidence of the benefits of lowering blood pressure, conventional treatment does not normalize the burden of major cardiovascular events in... (Review)
Review
Despite the substantial evidence of the benefits of lowering blood pressure, conventional treatment does not normalize the burden of major cardiovascular events in patients with hypertension. Data now suggest that the nature of the antihypertensive agent used may have an important impact on long-term cardiovascular outcomes, including stroke. Optimal treatment should provide powerful 24-hour blood pressure control, including during the early morning hours when the risk of stroke is highest. In addition, antihypertensive therapies selected should have positive blood pressure-independent effects on stroke risk. In contrast to angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers (ARBs) provide consistent benefits in stroke protection beyond blood pressure lowering. The ARB telmisartan has a particularly interesting profile for stroke management. Selective angiotensin II type 1 receptor blockade and 24-hour blood pressure control with telmisartan provide the potential for improved stroke prevention. This will be investigated in the Prevention Regimen for Effectively Avoiding Second Strokes (PROFESS) study.
Topics: Angiotensin II Type 1 Receptor Blockers; Angiotensin-Converting Enzyme Inhibitors; Antihypertensive Agents; Benzimidazoles; Benzoates; Europe; Humans; Hypertension; Stroke; Telmisartan
PubMed: 17666193
DOI: 10.1016/j.amjcard.2007.05.010 -
South African Medical Journal =... May 2011We aimed to establish the pathological types of stroke in two incident populations in Tanzania, one rural and one urban, and to examine the clinical utility of the... (Comparative Study)
Comparative Study
OBJECTIVES
We aimed to establish the pathological types of stroke in two incident populations in Tanzania, one rural and one urban, and to examine the clinical utility of the Siriraj and Allen scores in identifying stroke sub-types.
DESIGN
This prospective community-based study identified cases as part of a stroke incidence study. Each patient underwent a full assessment including recording demographic information, taking a medical and drug history, and physical examination. A computed tomography (CT) head scan was used to classify strokes as resulting from a cerebral haemorrhage or ischaemia. The results were compared with the Siriraj and Allen scores, obtained from clinical findings.
RESULTS
One hundred and thirty-two incident stroke cases were identified in the rural Hai demographic surveillance site (DSS) and 69 in the urban Dar-es-Salaam DSS; 63 patients with stroke due to ischaemia or cerebral haemorrhage from Hai and 17 from Dares-Salaam had a CT scan within 15 days of the stroke. Stroke was identified as due to ischaemia in 52 cases (82.5%) and to cerebral haemorrhage in 11 (17.5%) in Hai, and as due to ischaemia in 14 cases (82.4%) and to cerebral haemorrhage in 3 (17.6%) in Dar-es-Salaam. In both sites Siriraj and Allen scores were found to be of little value in predicting stroke sub-type.
CONCLUSIONS
The ratio of ischaemic to haemorrhagic stroke is much higher in our cohort than previously reported in sub-Saharan Africa, and is closer to that in high-income countries.
Topics: Adult; Aged; Aged, 80 and over; Diagnosis, Differential; Female; Humans; Incidence; Male; Middle Aged; Population Surveillance; Prospective Studies; Rural Population; Stroke; Tanzania; Tomography, X-Ray Computed; Urban Population; Young Adult
PubMed: 21837879
DOI: 10.7196/samj.4511 -
DNA and Cell Biology Jan 2020There is increasing evidence suggesting that dysregulation of miR-155 and its target angiotensin receptor type 1 (AT1R) are linked to the incidence of ischemic stroke...
There is increasing evidence suggesting that dysregulation of miR-155 and its target angiotensin receptor type 1 (AT1R) are linked to the incidence of ischemic stroke (IS), but the underlying mechanisms remain to be clarified. In this study, we therefore sought to investigate how and polymorphisms affect IS risk. We included 579 IS patients and 509 age-matched controls in the present analysis, genotyping individuals for the rs767649 polymorphism in , as well as for the rs1492099 and rs275653 polymorphisms in via iMLDR-TM genotyping technology. The allele and genotype frequencies for the assessed polymorphisms were comparable in IS patients and controls, without any detectable association between haplotype and IS risk. We conducted additional trial of ORG 10172 in acute stroke treatment-mediated stratification, which indicated that the rs1492099 T allele was linked to a decreased risk of large-artery atherosclerosis (LAA) stroke. We further found that those with the rs275653 AA genotype had a decreased risk of small-artery occlusion (SAO) strokes. We further confirmed elevated miR-155 expression in IS patients, but observed no link between the rs767649 polymorphism and expression of this microRNA. Similarly, rs1492099 and rs275653 polymorphisms did not impact expression levels. The rs767649 polymorphism does not seem to be a key determinant of IS risk, whereas the rs1492099 polymorphism is linked to reduced LAA-stroke risk, and the rs275653 AA genotype is potentially protective against SAO strokes.
Topics: Aged; Alleles; Asian People; Brain Ischemia; China; Female; Gene Expression Regulation; Gene Frequency; Genetic Predisposition to Disease; Genotype; Humans; Male; MicroRNAs; Middle Aged; Polymorphism, Single Nucleotide; Receptor, Angiotensin, Type 1; Risk Factors; Stroke
PubMed: 31721599
DOI: 10.1089/dna.2019.4948 -
Circulation Jan 2019The MOMENTUM 3 study (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3) has demonstrated that the... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
The MOMENTUM 3 study (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3) has demonstrated that the HeartMate 3 (HM3) pump is associated with reduced strokes compared with the HeartMate II (HMII) device. We now perform a comprehensive analysis of stroke events to evaluate their longitudinal occurrence, clinical correlates, patterns, and impact on outcome across the 2-year duration of support.
METHODS
MOMENTUM 3 is a randomized controlled trial of the HM3 centrifugal-flow pump versus the HMII axial-flow pump in patients with advanced heart failure, regardless of the intended goal of support (bridge to transplantation or destination therapy). Baseline and postimplantation clinical correlates of stroke events were assessed with multivariable analyses. Longitudinal patterns, including device association, type of stroke (hemorrhagic versus ischemic), changing severity of impairment assessed with the modified Rankin Scale (disabling [modified Rankin Scale score >3] versus nondisabling [modified Rankin Scale score ≤3]) over time, and association with outcome, were determined.
RESULTS
In 361 patients with the intended implant (189 HM3 and 172 HMII), 65 strokes (40 ischemic strokes and 25 hemorrhagic strokes) occurred in 52 patients at a median of 131 (range, 1-733) days. No difference in stroke rate was noted between 0 and 180 days of follow-up between devices. However, stroke incidence in the long-term period (181-730 days after left ventricular assist device) was 3.3 times lower for the HM3 group (HM3: 0.04 versus HMII: 0.13 events per patient-year; odds ratio, 0.23; 95% CI, 0.08-0.63; P=0.01). Treatment with the HM3 pump was the only independent predictor of lower stroke events. We found no direct association of blood pressure or antithrombotic regimens with observed stroke rates. A stroke event significantly lowered 2-year postimplantation survival regardless of subtype or initial severity of neurological impairment compared with patients without a stroke (43±12% for hemorrhagic stroke, 57±9% for ischemic stroke, 51±11% for disabling, and 51±11% for nondisabling compared with 85±2% 2-year survival for patients without stroke).
CONCLUSIONS
The HM3 pump is associated with a marked reduction in stroke rates compared with the HMII device, with benefits observed in the long-term period (>6 months). The occurrence of stroke of any type (hemorrhagic and ischemic) or of any functional severity (disabling and nondisabling) is predictive of a poor 2-year clinical outcome.
CLINICAL TRIAL REGISTRATION
URL: https://www.clinicaltrials.gov/ . Unique identifier: NCT02224755.
Topics: Aged; Brain Ischemia; Disability Evaluation; Female; Heart Failure; Heart-Assist Devices; Humans; Intracranial Hemorrhages; Male; Middle Aged; Prospective Studies; Prosthesis Design; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome; United States; Ventricular Function, Left
PubMed: 30586698
DOI: 10.1161/CIRCULATIONAHA.118.037231 -
Journal of Cardiothoracic and Vascular... Dec 2023Stroke after thoracic aortic surgery is a complication that is associated with poor outcomes. The aim is to characterize the intraoperative risk factors for stroke...
OBJECTIVES
Stroke after thoracic aortic surgery is a complication that is associated with poor outcomes. The aim is to characterize the intraoperative risk factors for stroke development.
DESIGN
A retrospective analysis.
SETTING
Tertiary, high-volume cardiac surgery center.
PARTICIPANTS
Patients who had surgical repair of thoracic aortic diseases from January 1, 2017, through December 31, 2021.
INTERVENTIONS
None.
MEASUREMENTS AND MAIN RESULTS
A total of 704 patients were included, of whom 533 had ascending aortic aneurysms, and 171 had type A aortic dissection. The incidence of postoperative stroke was 4.5% (95% CI 2.9%-6.6%) for ascending aortic aneurysms compared with 12.3% (95% CI 7.8%-18.16%) in type-A aortic dissections. Patients who developed postoperative strokes had significantly lower intraoperative hemoglobin median (7.5 gm/dL [IQR 6.8-8.6] v 8.55 gm/dL [IQR 7.3-10.0]; p < 0.001). The median cardiopulmonary bypass time was 185 minutes (IQR 136-328) in the stroke group versus 156 minutes (IQR 113-206) in the nonstroke group (p = 0.014). Circulatory arrest was used in 57.8% versus 38.5% of the nonstroke patients (p = 0.017). The initial temperature after leaving the operating room was lower, with a median of 35.0°C (IQR 34-35.92) in the stroke group versus 35.5°C (IQR 35-36) in the nonstroke cohort (p = 0.021).
CONCLUSIONS
This single-center study highlighted the potential importance of intra-operative factors in preventing stroke. Lower hemoglobin, longer duration of cardiopulmonary bypass, deep hypothermic circulatory arrest, and postoperative hypothermia are potential risk factors for postoperative stroke. Further studies are needed to prevent this significant complication in patients with thoracic aortic diseases.
Topics: Humans; Retrospective Studies; Aorta, Thoracic; Stroke; Risk Factors; Aortic Aneurysm; Aortic Dissection; Aortic Diseases; Cardiac Surgical Procedures; Hemoglobins; Aortic Aneurysm, Thoracic; Circulatory Arrest, Deep Hypothermia Induced; Treatment Outcome
PubMed: 37716892
DOI: 10.1053/j.jvca.2023.08.135 -
Annals of Neurology Aug 2023Acute dizziness/vertigo is usually due to benign inner-ear causes but is occasionally due to dangerous neurologic ones, particularly stroke. Because symptoms and signs... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Acute dizziness/vertigo is usually due to benign inner-ear causes but is occasionally due to dangerous neurologic ones, particularly stroke. Because symptoms and signs overlap, misdiagnosis is frequent and overuse of neuroimaging is common. We assessed the accuracy of bedside findings to differentiate peripheral vestibular from central neurologic causes.
METHODS
We performed a systematic search (MEDLINE and Embase) to identify studies reporting on diagnostic accuracy of physical examination in adults with acute, prolonged dizziness/vertigo ("acute vestibular syndrome" [AVS]). Diagnostic test properties were calculated for findings. Results were stratified by examiner type and stroke location.
RESULTS
We identified 6,089 citations and included 14 articles representing 10 study cohorts (n = 800). The Head Impulse, Nystagmus, Test of Skew (HINTS) eye movement battery had high sensitivity 95.3% (95% confidence interval [CI] = 92.5-98.1) and specificity 92.6% (95% CI = 88.6-96.5). Sensitivity was similar by examiner type (subspecialists 94.3% [95% CI = 88.2-100.0] vs non-subspecialists 95.0% [95% CI = 91.2-98.9], p = 0.55), but specificity was higher among subspecialists (97.6% [95% CI = 94.9-100.0] vs 89.1% [95% CI = 83.0-95.2], p = 0.007). HINTS sensitivity was lower in anterior cerebellar artery (AICA) than posterior inferior cerebellar artery (PICA) strokes (84.0% [95% CI = 65.3-93.6] vs 97.7% [95% CI = 93.3-99.2], p = 0.014) but was "rescued" by the addition of bedside hearing tests (HINTS+). Severe (grade 3) gait/truncal instability had high specificity 99.2% (95% CI = 97.8-100.0) but low sensitivity 35.8% (95% CI = 5.2-66.5). Early magnetic resonance imaging (MRI)-diffusion-weighted imaging (DWI; within 24-48 hours) was falsely negative in 15% of strokes (sensitivity 85.1% [95% CI = 79.2-91.0]).
INTERPRETATION
In AVS, HINTS examination by appropriately trained clinicians can differentiate peripheral from central causes and has higher diagnostic accuracy for stroke than MRI-DWI in the first 24-48 hours. These techniques should be disseminated to all clinicians evaluating dizziness/vertigo. ANN NEUROL 2023;94:295-308.
Topics: Adult; Humans; Dizziness; Vertigo; Eye Movements; Nystagmus, Pathologic; Stroke; Acute Disease; Diagnostic Tests, Routine
PubMed: 37038843
DOI: 10.1002/ana.26661 -
Stroke Nov 2021Less 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....
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.
Topics: Adult; Aged; Calcineurin Inhibitors; Female; Heart Transplantation; Humans; Immunosuppression Therapy; Immunosuppressive Agents; Incidence; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Risk Factors; Sirolimus; Stroke
PubMed: 34470491
DOI: 10.1161/STROKEAHA.121.034874