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Choi SE, Bucci T, Huang JY, Yiu KH, Tsang CT, Lau KK, Hill A, Irving G, Lip GY, Abdul-Rahim AH. Early statin use is associated with improved survival and cardiovascular outcomes in patients with atrial fibrillation and recent ischaemic stroke: A propensity-matched analysis of a global federated health database. Eur Stroke J 2024:23969873241274213. [PMID: 39254367 DOI: 10.1177/23969873241274213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024] Open
Abstract
INTRODUCTION Statins reduce recurrent stroke and cardiovascular events in patients with non-cardioembolic stroke. The benefits of statins in patients with AF and recent IS remain unclear. We aimed to investigate the benefits of statins in patients with AF and recent IS. PATIENTS AND METHODS This retrospective, cohort study was conducted using deidentified electronic medical records within TriNetX platform. Patients with AF and recent IS, who received statins within 28 days of their index stroke were propensity score-matched with those who did not. Patients were followed up for up to 2 years. Primary outcomes were the 2-year risk of recurrent IS, all-cause mortality and the composite outcome of all-cause mortality, recurrent IS, transient ischaemic attack (TIA), and acute myocardial infarction (MI). Secondary outcomes were the 2-year risk of TIA, intracranial haemorrhage (ICH), acute MI, and hospital readmission. Cox regression analyses were used to calculate hazard ratios (HRs) with 95% confidence intervals (95%CI). RESULTS Of 20,902 patients with AF and recent IS, 7500 (35.9%) received statins within 28 days of their stroke and 13,402 (64.1%) did not. 11,182 patients (mean age 73.7 ± 11.5; 5277 (47.2%) female) remained after propensity score matching. Patients who received early statins had significantly lower risk of recurrent IS (HR: 0.45, 95%CI: 0.41-0.48, p < 0.001), mortality (HR: 0.75, 95%CI: 0.66-0.84, p < 0.001), the composite outcome (HR: 0.48, 95%CI: 0.45-0.52, p < 0.001), TIA (HR: 0.37, 95%CI: 0.30-0.44, p < 0.001), ICH (HR: 0.59, 95%CI: 0.47-0.72, p < 0.001 ), acute MI (HR: 0.35, 95%CI: 0.30-0.42, p < 0.001) and hospital readmission (HR: 0.46, 95%CI: 0.42-0.50, <0.001). Beneficial effects of early statins were evident in the elderly, different ethnic groups, statin dose intensity, and AF subtypes, large vessel occlusion and embolic strokes and within the context of statin lipophilicity, optimal LDL-cholesterol levels, various cardiovascular comorbidities, treatment with intravenous thrombolysis or endovascular thrombectomy, and NIHSS 0-5 and NIHSS > 5 subgroups. DISCUSSION AND CONCLUSION Patients with AF and recent IS, who received early statins, had a lower risk of recurrent stroke, death, and other cardiovascular outcomes including ICH, compared to those who did not.
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Affiliation(s)
- Sylvia E Choi
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Tommaso Bucci
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Clinical Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Jia-Yi Huang
- Cardiology Division, Department of Medicine, The University of Hong Kong Shen Zhen Hospital, Shen Zhen, China
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Kai-Hang Yiu
- Cardiology Division, Department of Medicine, The University of Hong Kong Shen Zhen Hospital, Shen Zhen, China
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Christopher Tw Tsang
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Kui Kai Lau
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, China
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Stroke Division, Department of Medicine for Older People, Whiston Hospital, Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, UK
| | - Greg Irving
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Health Research Institute, Edge Hill University Faculty of Health and Social Care, Ormskirk, UK
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Stroke Division, Department of Medicine for Older People, Whiston Hospital, Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, UK
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Johansen MC, von Rennenberg R, Nolte CH, Jensen M, Bustamante A, Katan M. Role of Cardiac Biomarkers in Stroke and Cognitive Impairment. Stroke 2024; 55:2376-2384. [PMID: 39016019 PMCID: PMC11347090 DOI: 10.1161/strokeaha.123.044143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
This topical review assesses the growing role of cardiac biomarkers beyond cardiovascular health and focuses on their importance in stroke and dementia. The first part describes blood-based cardiac biomarkers in patients with stroke and highlights applications in the setting of early diagnosis, poststroke complications, outcome prediction as well as secondary prevention. Among other applications, natriuretic peptides can be helpful in differentiating stroke subtypes. They are also currently being investigated to guide prolonged ECG monitoring and secondary prevention in patients with stroke. Elevated cardiac troponin after ischemic stroke can provide information about various poststroke complications recently termed the stroke-heart syndrome. The second part focuses on the role of cardiac biomarkers in vascular cognitive impairment and dementia, emphasizing their association with structural brain lesions. These lesions such as silent brain infarcts and white matter hyperintensities often co-occur with cardiac disease and may be important mediators between cardiovascular disease and subsequent cognitive decline. ECG and echocardiogram measurements, in addition to blood-based biomarkers, show consistent associations with vascular brain changes and incident dementia, suggesting a role in indicating risk for cognitive decline. Together, the current evidence suggests that cardiac blood-based, electrophysiological, and imaging biomarkers can be used to better understand the heart and brain connection in the setting of not only stroke but also dementia.
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Affiliation(s)
- Michelle C. Johansen
- Department of Neurology, Cerebrovascular Division, John Hopkins University School of Medicine, Baltimore, USA
| | - Regina von Rennenberg
- Department of Neurology with experimental Neurology and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H. Nolte
- Department of Neurology with experimental Neurology and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Märit Jensen
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alejandro Bustamante
- Stroke Unit, Department of Neurology, Hospital Universitari Germans Trias i Pujol, Germans Trias i Pujol Research Institute (IGTP) Barcelona, Spain
| | - Mira Katan
- Department of Neurology, Stroke Center, University and University Hospital of Basel, Basel, Switzerland
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Zarei H, Ebrahimzade M, Hajiqasemi M, Janmohamadi M, Adel Ramawad H, Haji Aghajani M, Yousefifard M. Diagnostic accuracy of 3-item stroke scale for detection of cerebral large vessel occlusion: A systematic review and meta-analysis. Am J Emerg Med 2024; 83:114-125. [PMID: 39003928 DOI: 10.1016/j.ajem.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/26/2024] [Accepted: 07/01/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Prompt identification of large vessel occlusion (LVO) in acute ischemic stroke (AIS) is crucial for expedited endovascular therapy (EVT) and improved patient outcomes. Prehospital stroke scales, such as the 3-Item Stroke Scale (3I-SS), could be beneficial in detecting LVO in suspected patients. This meta-analysis evaluates the diagnostic accuracy of 3I-SS for LVO detection in AIS. METHODS A systematic search was conducted in Medline, Embase, Scopus, and Web of Science databases until February 2024 with no time and language restrictions. Prehospital and in-hospital studies reporting diagnostic accuracy were included. Review articles, studies without reported 3I-SS cut-offs, and studies lacking the required data were excluded. Pooled effect sizes, including area under the curve (AUC), sensitivity, specificity, diagnostic odds ratio (DOR), positive and negative likelihood ratios (PLR and NLR) with 95% confidence intervals (CI) were calculated. RESULTS Twenty-two studies were included in the present meta-analysis. A 3I-SS score of 2 or higher demonstrated sensitivity of 76% (95% CI: 52%-90%) and specificity of 74% (95% CI: 57%-86%) as the optimal cut-off, with an AUC of 0.81 (95% CI: 0.78-0.84). DOR, PLR, and NLR, were 9 (95% CI: 5-15), 2.9 (95% CI: 2.0-4.3) and 0.32 (95% CI: 0.17-0.61), respectively. Sensitivity analysis confirmed the analyses' robustness in suspected to stroke patients, anterior circulation LVO, assessment by paramedics, and pre-hospital settings. Meta-regression analyses pinpointed LVO definition (anterior circulation, posterior circulation) and patient setting (suspected stroke, confirmed stroke) as potential sources of heterogeneity. CONCLUSION 3I-SS demonstrates good diagnostic accuracy in identifying LVO stroke and may be valuable in the prompt identification of patients for direct transfer to comprehensive stroke centers.
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Affiliation(s)
- Hamed Zarei
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Mandana Ebrahimzade
- Department of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Hajiqasemi
- Department of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahrokh Janmohamadi
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamzah Adel Ramawad
- Department of Emergency Medicine, NYC Health & Hospitals Coney Island, New York, NY, USA
| | - Mohammad Haji Aghajani
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mahmoud Yousefifard
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran.
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Lee S, Yuan F, Garcia M, MacLellan A, Mlynash M, Meseguer E, Arnold M, Häusler KG, Sporns PB, Perera KS. Thrombectomy in young adults with embolic stroke of undetermined source: Analysis of the Young ESUS study. J Stroke Cerebrovasc Dis 2024; 33:107811. [PMID: 38866118 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/05/2024] [Accepted: 06/08/2024] [Indexed: 06/14/2024] Open
Abstract
OBJECTIVES Embolic Stroke of Undetermined Source (ESUS) is a distinct stroke entity that disproportionately affects young adults. We sought to describe characteristics, workup and outcomes of young adult ESUS patients who underwent thrombectomy, and compare outcomes to those reported in different age groups. MATERIALS AND METHODS Young-ESUS is a multicenter longitudinal cohort study that enrolled consecutive patients aged 21-50 years at 41 stroke centers in 13 countries between 2017- 2019. Between-group comparisons were performed using Wilcoxon rank sum test for continuous variables or Fisher's exact test for binary variables. Distribution of functional outcomes after thrombectomy for our young adult cohort versus pediatric and older adult cohorts reported in the literature were described using the Kruskal-Wallis test. RESULTS Of 535 patients enrolled in Young-ESUS, 65 (12.1%) were treated with endovascular thrombectomy. Patients who underwent thrombectomy were more likely to undergo in-depth cardiac testing than those who did not, but cardiac abnormalities were not detected more often in this group. Among thrombectomy patients, 35/63 (55.6%) had minimal to no functional disability at follow up. When adjusted for age, stroke severity and IV alteplase, the odds of achieving favorable outcome did not differ between treated versus untreated patients. CONCLUSIONS Thrombectomy is not rare in young adults with ESUS. Despite extensive workup, cardiac abnormalities were not more prevalent in the thrombectomy group. More research to determine optimal workup, etiologic factors and favorable outcome of stroke across the lifespan is needed.
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Affiliation(s)
- Sarah Lee
- Stanford Stroke Center, Department of Neurology, Stanford School of Medicine, Stanford, CA, USA; Division of Child Neurology, Department of Neurology, Stanford School of Medicine, Stanford, CA, USA.
| | - Fei Yuan
- Department of Statistics, Population Health Research Institute, Hamilton, ON, Canada
| | - Madelleine Garcia
- Stanford Stroke Center, Department of Neurology, Stanford School of Medicine, Stanford, CA, USA
| | - Adam MacLellan
- Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Michael Mlynash
- Stanford Stroke Center, Department of Neurology, Stanford School of Medicine, Stanford, CA, USA
| | | | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Karl Georg Häusler
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Peter B Sporns
- Department of Diagnostic and Interventional Radiology, University Hospital Basel, Basel, Switzerland
| | - Kanjana S Perera
- Department of Medicine (Neurology), McMaster University/ Population Health Research Institute/ Hamilton Health Sciences, Hamilton, ON, Canada
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Muacevic A, Adler JR, Nevin C, Ranasinghe T, Jacob S, Ferari C, Adcock A. Incidence of Atrial Fibrillation in Large Vessel Occlusion and Large Embolic Stroke of Undetermined Source. Cureus 2023; 15:e33700. [PMID: 36793841 PMCID: PMC9925036 DOI: 10.7759/cureus.33700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Large vessel occlusion (LVO) stroke is a common presentation of acute ischemic stroke and is often unknown or cryptogenic in etiology. There is a strong association between atrial fibrillation (AF) and cryptogenic LVO stroke, making it a unique stroke subgroup. Therefore, we propose that any LVO stroke meeting the criteria for an embolic stroke of an undetermined source (ESUS) be classified as large ESUS (LESUS). The purpose of this retrospective cohort study was to report the etiology of anterior LVO strokes that underwent endovascular thrombectomy. METHODS This was a single-center retrospective cohort study characterizing the etiology of acute anterior circulation LVO strokes that received emergent endovascular thrombectomy from 2011 to 2018. Patients with LESUS designation at hospital discharge were changed to cardioembolic etiology if AF was discovered during the two-year follow-up period. Results: Overall, 155 (45%) of 307 patients in the study were found to have AF. New onset AF was discovered in 12 (23%) of 53 LESUS patients after hospitalization. Furthermore, eight (35%) of 23 LESUS patients who received extended cardiac monitoring were found to have AF. CONCLUSION Nearly half the patients with LVO stroke who received endovascular thrombectomy were found to have AF. With the use of extended cardiac monitoring devices after hospitalization, AF is frequently discovered in patients with LESUS and may change the secondary stroke prevention strategy.
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Masiliūnas R, Dapkutė A, Grigaitė J, Lapė J, Valančius D, Bacevičius J, Katkus R, Vilionskis A, Klimašauskienė A, Ekkert A, Jatužis D. High Prevalence of Atrial Fibrillation in a Lithuanian Stroke Patient Cohort. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:800. [PMID: 35744063 PMCID: PMC9230037 DOI: 10.3390/medicina58060800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/10/2022] [Accepted: 06/10/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with a five-fold increased risk for acute ischemic stroke (AIS). We aimed to estimate the prevalence of AF in a Lithuanian cohort of stroke patients, and its impact on patients regarding case fatality, functional outcome, and health-related quality of life (HRQoL) at 90 days. Materials and Methods: A single-center prospective study was carried out for four non-consecutive months between December 2018 and July 2019 in one of the two comprehensive stroke centers in Eastern Lithuania. A telephone-based follow-up was conveyed at 90 days using the modified Rankin Scale (mRS) and EuroQoL five-dimensional three-level descriptive system (EQ-5D-3L) with a self-rated visual analog scale (EQ-VAS). One-year case fatality was investigated. Results: We included 238 AIS patients with a mean age of 71.4 ± 11.9 years of whom 45.0% were female. A striking 97 (40.8%) AIS patients had a concomitant AF, in 68 (70.1%) of whom the AF was pre-existing. The AIS patients with AF were at a significantly higher risk for a large vessel occlusion (LVO; odds ratio 2.72 [95% CI 1.38−5.49], p = 0.004), and had a more severe neurological impairment at presentation (median NIHSS score (interquartile range): 9 (6−16) vs. 6 (3−9), p < 0.001). The LVO status was only detected in those who had received computed tomography angiography. Fifty-five (80.9%) patients with pre-existing AF received insufficient anticoagulation at stroke onset. All patients received a 12-lead ECG, however, in-hospital 24-h Holter monitoring was only performed in 3.4% of AIS patients without pre-existing AF. Although multivariate analyses found no statistically significant difference in one-year stroke patient survival and favorable functional status (mRS 0−2) at 90 days, when adjusted for age, gender, reperfusion treatment, baseline functional status, and baseline NIHSS, stroke patients with AF had a significantly poorer self-perceived HRQoL, indicated by a lower EQ-VAS score (regression coefficient ± standard error: β = −11.776 ± 4.850, p = 0.017). Conclusions: In our single-center prospective observational study in Lithuania, we found that 40.8% of AIS patients had a concomitant AF, were at a higher risk for an LVO, and had a significantly poorer self-perceived HRQoL at 90 days. Despite the high AF prevalence, diagnostic tools for subclinical AF were greatly underutilized.
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Affiliation(s)
- Rytis Masiliūnas
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania; (A.D.); (J.G.); (D.V.); (A.K.); (A.E.); (D.J.)
| | - Austėja Dapkutė
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania; (A.D.); (J.G.); (D.V.); (A.K.); (A.E.); (D.J.)
| | - Julija Grigaitė
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania; (A.D.); (J.G.); (D.V.); (A.K.); (A.E.); (D.J.)
| | - Jokūbas Lapė
- Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania;
| | - Domantas Valančius
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania; (A.D.); (J.G.); (D.V.); (A.K.); (A.E.); (D.J.)
| | - Justinas Bacevičius
- Center of Cardiology and Angiology, Vilnius University, 08661 Vilnius, Lithuania; (J.B.); (R.K.)
| | - Rimgaudas Katkus
- Center of Cardiology and Angiology, Vilnius University, 08661 Vilnius, Lithuania; (J.B.); (R.K.)
| | | | - Aušra Klimašauskienė
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania; (A.D.); (J.G.); (D.V.); (A.K.); (A.E.); (D.J.)
| | - Aleksandra Ekkert
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania; (A.D.); (J.G.); (D.V.); (A.K.); (A.E.); (D.J.)
| | - Dalius Jatužis
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania; (A.D.); (J.G.); (D.V.); (A.K.); (A.E.); (D.J.)
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Optimization of Large Vessel Occlusion Detection in Acute Ischemic Stroke Using Machine Learning Methods. Life (Basel) 2022; 12:life12020230. [PMID: 35207517 PMCID: PMC8877679 DOI: 10.3390/life12020230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 12/18/2022] Open
Abstract
The early detection of large-vessel occlusion (LVO) strokes is increasingly important as these patients are potential candidates for endovascular therapy, the availability of which is limited. Prehospital LVO detection scales mainly contain symptom variables only; however, recent studies revealed that other types of variables could be useful as well. Our aim was to comprehensively assess the predictive ability of several clinical variables for LVO prediction and to develop an optimal combination of them using machine learning tools. We have retrospectively analysed data from a prospectively collected multi-centre stroke registry. Data on 41 variables were collected and divided into four groups (baseline vital parameters/demographic data, medical history, laboratory values, and symptoms). Following the univariate analysis, the LASSO method was used for feature selection to select an optimal combination of variables, and various machine learning methods (random forest (RF), logistic regression (LR), elastic net method (ENM), and simple neural network (SNN)) were applied to optimize the performance of the model. A total of 526 patients were included. Several neurological symptoms were more common and more severe in the group of LVO patients. Atrial fibrillation (AF) was more common, and serum white blood cell (WBC) counts were higher in the LVO group, while systolic blood pressure (SBP) was lower among LVO patients. Using the LASSO method, nine variables were selected for modelling (six symptom variables, AF, chronic heart failure, and WBC count). When applying machine learning methods and 10-fold cross validation using the selected variables, all models proved to have an AUC between 0.736 (RF) and 0.775 (LR), similar to the performance of National Institutes of Health Stroke Scale (AUC: 0.790). Our study highlights that, although certain neurological symptoms have the best ability to predict an LVO, other variables (such as AF and CHF in medical history and white blood cell counts) should also be included in multivariate models to optimize their efficiency.
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Nicholls JK, Ince J, Minhas JS, Chung EML. Emerging Detection Techniques for Large Vessel Occlusion Stroke: A Scoping Review. Front Neurol 2022; 12:780324. [PMID: 35095726 PMCID: PMC8796731 DOI: 10.3389/fneur.2021.780324] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/13/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Large vessel occlusion (LVO) is the obstruction of large, proximal cerebral arteries and can account for up to 46% of acute ischaemic stroke (AIS) when both the A2 and P2 segments are included (from the anterior and posterior cerebral arteries). It is of paramount importance that LVO is promptly recognised to provide timely and effective acute stroke management. This review aims to scope recent literature to identify new emerging detection techniques for LVO. As a good comparator throughout this review, the commonly used National Institutes of Health Stroke Scale (NIHSS), at a cut-off of ≥11, has been reported to have a sensitivity of 86% and a specificity of 60% for LVO. Methods: Four electronic databases (Medline via OVID, CINAHL, Scopus, and Web of Science), and grey literature using OpenGrey, were systematically searched for published literature investigating developments in detection methods for LVO, reported from 2015 to 2021. The protocol for the search was published with the Open Science Framework (10.17605/OSF.IO/A98KN). Two independent researchers screened the titles, abstracts, and full texts of the articles, assessing their eligibility for inclusion. Results: The search identified 5,082 articles, in which 2,265 articles were screened to assess their eligibility. Sixty-two studies remained following full-text screening. LVO detection techniques were categorised into 5 groups: stroke scales (n = 30), imaging and physiological methods (n = 15), algorithmic and machine learning approaches (n = 9), physical symptoms (n = 5), and biomarkers (n = 3). Conclusions: This scoping review has explored literature on novel and advancements in pre-existing detection methods for LVO. The results of this review highlight LVO detection techniques, such as stroke scales and biomarkers, with good sensitivity and specificity performance, whilst also showing advancements to support existing LVO confirmatory methods, such as neuroimaging.
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Affiliation(s)
- Jennifer K. Nicholls
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Medical Physics, University Hospitals of Leicester, NHS Trust, Leicester, United Kingdom
| | - Jonathan Ince
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Jatinder S. Minhas
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Emma M. L. Chung
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Medical Physics, University Hospitals of Leicester, NHS Trust, Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
- School of Life Course Sciences, King's College London, London, United Kingdom
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9
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Kuohn LR, Herman AL, Soto AL, Brown SC, Gilmore EJ, Hirsch LJ, Matouk CC, Sheth KN, Kim JA. Hospital Revisits for Post-Ischemic Stroke Epilepsy after Acute Stroke Interventions. J Stroke Cerebrovasc Dis 2022; 31:106155. [PMID: 34688213 PMCID: PMC8766898 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/28/2021] [Accepted: 10/02/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Improvements in acute stroke care have led to an increase in ischemic stroke survivors, who are at risk for development of post-ischemic stroke epilepsy (PISE). The impact of therapies such as thrombectomy and thrombolysis on risk of hospital revisits for PISE is unclear. We utilized administrative data to investigate the association between stroke treatment and PISE-related visits. MATERIALS AND METHODS Using claims data from California, New York, and Florida, we performed a retrospective analysis of adult survivors of acute ischemic strokes. Patients with history of epilepsy, trauma, infections, or tumors were excluded. Included patients were followed for a primary outcome of revisits for seizures or epilepsy. Cox proportional hazards regression was used to identify covariates associated with PISE. RESULTS In 595,545 included patients (median age 74 [IQR 21], 52% female), the 6-year cumulative rate of PISE-related revisit was 2.20% (95% CI 2.16-2.24). In multivariable models adjusting for demographics, comorbidities, and indicators of stroke severity, IV-tPA (HR 1.42, 95% CI 1.31-1.54, p<0.001) but not MT (HR 1.62, 95% CI 0.90-1.50, p=0.2) was associated with PISE-related revisit. Patients who underwent decompressive craniectomy experienced a 2-fold increase in odds for returning with PISE (HR 2.35, 95% CI 1.69-3.26, p<0.001). In-hospital seizures (HR 4.06, 95% CI 3.76-4.39, p<0.001) also elevated risk for PISE. SIGNIFICANCE We demonstrate that ischemic stroke survivors who received IV-tPA, underwent decompressive craniectomy, or experienced acute seizures were at increased risk PISE-related revisit. Close attention should be paid to these patients with increased potential for long-term development of and re-hospitalization for PISE.
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Affiliation(s)
- Lindsey R Kuohn
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Alison L Herman
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Alexandria L Soto
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Stacy C Brown
- Neuroscience Institute, The Queen’s Medical Center, Honolulu, HI
| | - Emily J Gilmore
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Lawrence J Hirsch
- Division of Epilepsy and EEG, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Charles C Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Jennifer A Kim
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT,Correspondence Author. Jennifer A. Kim, MD, Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St., LLCI Room 1004B, P.O. Box 208018, New Haven, CT 06520, USA,
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10
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Greer DM, Aparicio HJ, Siddiqi OK, Furie KL. Cardiac Diseases. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00032-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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11
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Cui J, Yang J, Zhang K, Xu G, Zhao R, Li X, Liu L, Zhu Y, Zhou L, Yu P, Xu L, Li T, Tian J, Zhao P, Yuan S, Wang Q, Guo L, Liu X. Machine Learning-Based Model for Predicting Incidence and Severity of Acute Ischemic Stroke in Anterior Circulation Large Vessel Occlusion. Front Neurol 2021; 12:749599. [PMID: 34925213 PMCID: PMC8675605 DOI: 10.3389/fneur.2021.749599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives: Patients with anterior circulation large vessel occlusion are at high risk of acute ischemic stroke, which could be disabling or fatal. In this study, we applied machine learning to develop and validate two prediction models for acute ischemic stroke (Model 1) and severity of neurological impairment (Model 2), both caused by anterior circulation large vessel occlusion (AC-LVO), based on medical history and neuroimaging data of patients on admission. Methods: A total of 1,100 patients with AC- LVO from the Second Hospital of Hebei Medical University in North China were enrolled, of which 713 patients presented with acute ischemic stroke (AIS) related to AC- LVO and 387 presented with the non-acute ischemic cerebrovascular event. Among patients with the non-acute ischemic cerebrovascular events, 173 with prior stroke or TIA were excluded. Finally, 927 patients with AC-LVO were entered into the derivation cohort. In the external validation cohort, 150 patients with AC-LVO from the Hebei Province People's Hospital, including 99 patients with AIS related to AC- LVO and 51 asymptomatic AC-LVO patients, were retrospectively reviewed. We developed four machine learning models [logistic regression (LR), regularized LR (RLR), support vector machine (SVM), and random forest (RF)], whose performance was internally validated using 5-fold cross-validation. The performance of each machine learning model for the area under the receiver operating characteristic curve (ROC-AUC) was compared and the variables of each algorithm were ranked. Results: In model 1, among the included patients with AC-LVO, 713 (76.9%) and 99 (66%) suffered an acute ischemic stroke in the derivation and external validation cohorts, respectively. The ROC-AUC of LR, RLR and SVM were significantly higher than that of the RF in the external validation cohorts [0.66 (95% CI 0.57–0.74) for LR, 0.66 (95% CI 0.57–0.74) for RLR, 0.55 (95% CI 0.45–0.64) for RF and 0.67 (95% CI 0.58–0.76) for SVM]. In model 2, 254 (53.9%) and 31 (37.8%) patients suffered disabling ischemic stroke in the derivation and external validation cohorts, respectively. There was no difference in AUC among the four machine learning algorithms in the external validation cohorts. Conclusions: Machine learning methods with multiple clinical variables have the ability to predict acute ischemic stroke and the severity of neurological impairment in patients with AC-LVO.
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Affiliation(s)
- Junzhao Cui
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jingyi Yang
- Department of Information Center, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Kun Zhang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Guodong Xu
- Department of Neurology, Hebei Province People's Hospital, Shijiazhuang, China
| | - Ruijie Zhao
- Department of Neurology, Xingtai People's Hospital, Xingtai, China
| | - Xipeng Li
- Department of Neurology, Xingtai People's Hospital, Xingtai, China
| | - Luji Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yipu Zhu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lixia Zhou
- Department of Medical Iconography, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ping Yu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lei Xu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Tong Li
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jing Tian
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Pandi Zhao
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Si Yuan
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qisong Wang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Li Guo
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaoyun Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.,Neuroscience Research Center, Medicine and Health Institute, Hebei Medical University, Shijiazhuang, China
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12
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Left Atrial Volume Index as a Predictor for Large-Vessel Occlusion in Cardiogenic Cerebral Infarction: A Single-Center Cohort Study. World Neurosurg 2021; 159:e79-e83. [PMID: 34883273 DOI: 10.1016/j.wneu.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The left atrial volume index (LAVI) is considered to be the most accurate index to estimate the size of the left atrium (LA). In this study, we investigated the relationship between LA size measured by LAVI and the occurrence of large-vessel occlusion (LVO) in patients with cardiogenic cerebral infarction (CCI). METHODS This retrospective single-center cohort study involved 118 patients with CCI within the internal carotid artery (ICA) or middle cerebral artery regions seen between January 2015 and July 2020. In all patients, the type of CCI was determined according to the Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Scores (TOAST) subtype diagnosis criteria. LVO was defined as positive when magnetic resonance imaging and computed tomography angiography showed ICA, M1, or M2 occlusion, with all others defined as non-LVO. Clinical characteristics, including LAVI, were evaluated in the records of several patients to investigate if they were risk factors for developing LVO. RESULTS Seventy patients (59%) were diagnosed as having LVO infarction (ICA occlusion, n = 19 [16%]; M1 occlusion, n = 26 [22%]; and M2 occlusion, n = 25 [21%]). Echocardiography showed no difference between LVO and non-LVO in terms of the ejection fraction (P = 0.64), LA dimension (P = 0.93), and LA volume (P = 0.06). However, LAVI significantly differed between the LVO and non-LVO groups (P = 0.02). Multivariate logistic regression analysis showed larger LAVI as a significant risk factor for LVO (P = 0.01). CONCLUSIONS Our findings suggest that a larger LAVI is a predictor of developing LVO in patients with CCI.
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13
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Wang J, Zhang J, Gong X, Zhang W, Zhou Y, Lou M. Prediction of large vessel occlusion for ischaemic stroke by using the machine learning model random forests. Stroke Vasc Neurol 2021; 7:94-100. [PMID: 34702747 PMCID: PMC9067264 DOI: 10.1136/svn-2021-001096] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/27/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUNDS The timely identification of large vessel occlusion (LVO) in the prehospital stage is extremely important given the disease morbidity and narrow time window for intervention. The current evaluation strategies still remain challenging. The goal of this study was to develop a machine learning (ML) model to predict LVO using prehospital accessible data. METHODS Consecutive acute ischaemic stroke patients who underwent CT or MR angiography and received reperfusion therapy within 8 hours from symptom onset in the Computer-based Online Database of Acute Stroke Patients for Stroke Management Quality Evaluation-II dataset from January 2016 to August 2021 were included. We developed eight ML models to integrate National Institutes of Health Stroke Scale (NIHSS) items with demographics, medical history and vascular risk factors to identify LVO and validate its efficiency. RESULTS Finally, 15 365 patients were included in the training set and 4215 patients were included in the test set. On the test set, random forests (RF), gradient boosting machine and extreme gradient boosting presented area under the curve (AUC) of 0.831 (95% CI 0.819 to 0.843), which were higher than other models, and RF presented the highest specificity (0.827). In addition, the AUC of RF was higher than other scales, and the accuracy of the model was improved by 6.4% compared with NIHSS. We also found the top five items of identifying LVO were total NIHSS score, gaze deviation, level of consciousness (LOC), LOC commands and motor left leg. CONCLUSIONS Our proposed model could be a useful screening tool to predict LVO based on the prehospital accessible medical data. TRIAL REGISTRATION NUMBER NCT04487340.
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Affiliation(s)
- Jianan Wang
- Department of Neurology, Zhejiang University School of Medicine Second Affiliated Hospital Department of Neurology, Hangzhou, Zhejiang, China
| | - Jungen Zhang
- Department of Neurology, Zhejiang University School of Medicine Second Affiliated Hospital Department of Neurology, Hangzhou, Zhejiang, China
| | - Xiaoxian Gong
- Department of Neurology, Zhejiang University School of Medicine Second Affiliated Hospital Department of Neurology, Hangzhou, Zhejiang, China
| | - Wenhua Zhang
- Department of Neurology, Zhejiang University School of Medicine Second Affiliated Hospital Department of Neurology, Hangzhou, Zhejiang, China
| | - Ying Zhou
- Department of Neurology, Zhejiang University School of Medicine Second Affiliated Hospital Department of Neurology, Hangzhou, Zhejiang, China
| | - Min Lou
- Department of Neurology, Zhejiang University School of Medicine Second Affiliated Hospital Department of Neurology, Hangzhou, Zhejiang, China
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14
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Butt W, Dhillon PS, Lenthall R, Malik L, Izzath W, Krishnan K, George B, Pointon K. Left Atrial Enlargement on Non-Gated CT Is Associated with Large Vessel Occlusion in Acute Ischaemic Stroke. Cerebrovasc Dis Extra 2021; 11:87-91. [PMID: 34551410 PMCID: PMC8543283 DOI: 10.1159/000519121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/17/2021] [Indexed: 11/29/2022] Open
Abstract
Background Recent reports have suggested that atrial fibrillation (AF) is more prevalent in the large vessel occlusion (LVO) subgroup of acute ischaemic stroke patients. Given the association between left atrial enlargement (LAE) and AF, we sought to evaluate the feasibility of assessing LAE on non-gated CT and its association with LVO in the hyperacute stroke setting. Methods We analysed our prospectively collected database that included all stroke patients referred for consideration of endovascular treatment between April 14, 2020, and May 21, 2020. During this period, a CT chest was included in our regional stroke protocol to aid triage of patients suspected for COVID-19 from which cardiac measurements were obtained. Patients were dichotomized into LVO and no-LVO groups, and LA measurements were trichotomized into normal, borderline, and enlarged. Univariate analyses were performed between groups. Results Of the included 38 patients, 21 were categorized as LVO and 17 as no LVO. There was a statistically significant association between LAE and LVO (p = 0.028). No significant difference was demonstrated between groups for the baseline AF and other clinical characteristics, except for baseline NIHSS (p = 0.0005). There was excellent inter- and intra-rater reliability (ICC = 0.969) for LA measurements. Conclusion Our study provides preliminary data to suggest LAE is more prevalent in the LVO stroke subgroup at presentation and can be reliably assessed on non-gated CT in the hyperacute setting. These findings have potential implications for stratifying secondary management and may prompt a more rigorous pursuit of occult AF or other cardiac causes of stroke.
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Affiliation(s)
- Waleed Butt
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Permesh Singh Dhillon
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Robert Lenthall
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Luqman Malik
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Wazim Izzath
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Kailash Krishnan
- Stroke Medicine, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Bindu George
- Cardiothoracic Radiology Department, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Kate Pointon
- Cardiothoracic Radiology Department, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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15
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Wang J, Gong X, Zhong W, Zhou Y, Lou M. Novel Prehospital Triage Scale for Detecting Large Vessel Occlusion and Its Cause. J Am Heart Assoc 2021; 10:e021201. [PMID: 34423654 PMCID: PMC8649265 DOI: 10.1161/jaha.121.021201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Patients with large vessel occlusion stroke (LVOS) need to be rapidly identified and transferred to comprehensive stroke centers. However, current prehospital evaluation and strategies still remain challenging. Methods and Results We retrospectively reviewed our prospectively collected database of patients with acute ischemic stroke (AIS). Based on the items of National Institutes of Health Stroke Scale and medical history that had a strong association with LVOS, we designed the 4‐item Stroke Scale (4I‐SS) and validated it in multi‐centers. The 4I‐SS incorporated gaze, level of consciousness, arm weakness, and atrial fibrillation. Receiver operating characteristic analysis was used to compare the 4I‐SS with previously established prehospital prediction scales. Finally, 1630 and 11 440 patients were included in the derivation and validation cohort, respectively. In the validation cohort, Youden Index, area under the curve, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the 4I‐SS≥4 to predict LVOS were 0.494, 0.800, 0.657, 0.837, 0.600, 0.868, and 0.788, respectively, and that of the 4I‐SS≥7 to predict basilar artery occlusion were 0.200, 0.669, 0.229, 0.971, 0.066, 0.974, and 0.899, respectively. Youden Index and area under the curve were higher than previously published scales for predicting LVOS. Further analysis showed that for predicting whether cardiogenic embolism was the cause, its accuracy was 0.922 when the 4I‐SS score, including atrial fibrillation, was ≥6, and its accuracy of predicting the occluded vessel was intracranial internal carotid artery or M1 segment of the middle cerebral artery when it was ≥7 was 0.590. Conclusions The 4I‐SS is an effective and simple tool that can identify LVOS and its cause. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03317639.
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Affiliation(s)
- Jianan Wang
- Department of Neurologythe Second Affiliated Hospital of Zhejiang University School of MedicineHangzhou China
| | - Xiaoxian Gong
- Department of Neurologythe Second Affiliated Hospital of Zhejiang University School of MedicineHangzhou China
| | - Wansi Zhong
- Department of Neurologythe Second Affiliated Hospital of Zhejiang University School of MedicineHangzhou China
| | - Ying Zhou
- Department of Neurologythe Second Affiliated Hospital of Zhejiang University School of MedicineHangzhou China
| | - Min Lou
- Department of Neurologythe Second Affiliated Hospital of Zhejiang University School of MedicineHangzhou China
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16
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Abstract
Atrial fibrillation (AF) is the most common cardiac arrythmia and a major cause of stroke, heart failure, sudden death, and cardiovascular morbidity. AF increases risk of thromboembolic stroke via stasis in the left atrium and subsequent embolization to the brain. In patients with acute ischemic stroke, it is essential that clinicians undertake careful investigation to search for AF. In these patients, up to 23.7% eventually are found to have underlying AF. Oral anticoagulation is effective in prevention of strokes secondary to AF, reducing overall stroke numbers by approximately 64%. Left atrial appendage occlusion is promising for prevention of stroke in AF.
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Affiliation(s)
- Hani Essa
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Andrew M Hill
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Department of Medicine for Older People, St Helens and Knowsley Teaching Hospitals NHS Trust, Marshalls Cross Road, St Helens, Liverpool WA9 3DA, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Sondra Skovvej, 15, Aalborg 9000, Denmark.
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17
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Dowbiggin PL, Infinger AI, Purick G, Swanson DR, Studnek JR. Inter-Rater Reliability of the FAST-ED in the Out-of-Hospital Setting. PREHOSP EMERG CARE 2021:1-8. [PMID: 33205683 DOI: 10.1080/10903127.2020.1852350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/10/2020] [Accepted: 11/13/2020] [Indexed: 10/23/2022]
Abstract
Introduction: Patients experiencing a large vessel occlusion stroke (LVOS) may require endovascular-capable centers and benefit from direct transport to such facilities, creating a need for an accurate prehospital assessment. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) is a secondary scale to identify LVOS. Currently, there is limited prospective evidence validating the use of the FAST-ED in the prehospital environment. This study aimed to evaluate the inter-rater reliability of the FAST-ED between patient care providers in the prehospital setting.Methods: This prospective study was conducted between 4/1/2018 and 7/1/2018 in a single municipal EMS agency that staffs two providers per ambulance with at least one being a paramedic. Patients were included based on paramedic impression that the patient was both having a stroke and greater than 18 years old. Each provider independently performed and documented a FAST-ED assessment on eligible patients. Data analysis consisted of performing inter-rater reliability using Cohen's Kappa on the FAST-ED score between primary and secondary providers. The FAST-ED was analyzed on an item level, an aggregate level (cumulative of all items), and using the defined cut point of ≥4. A sub-analysis determined if inter-rater reliability changed across provider certification.Results: There were 231 patients included in this analysis with an average age of 68.5 years and 135 (58.4%) female. Inter-rater reliability varied across individual items in the scale from 90.1% agreement to 82.5%. When analyzing inter-rater reliability of the aggregate FAST-ED score, the scale demonstrated 70.1% agreement (Kappa 0.66), considered substantial agreement. FAST-ED scores were analyzed using a cut point of ≥4. When using this cut point, there was 92.2% (Kappa 0.81) agreement between primary and secondary caregiver, demonstrating almost perfect agreement. Agreement was substantial across provider certifications including paramedics and EMTS.Conclusion: This study demonstrated high inter-rater reliability of the FAST-ED scale when performed in the prehospital setting on patients suspected of having a stroke. There were minimal differences in reliability based on provider certification, and item level analysis indicated substantial inter-rater reliability.
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Wu TY, Myall D, Palmer D, Beharry J, Lim JY, Mason DF, Reimers J, Duncan R, Weaver J, Collecutt W, Mouthaan P, Lim A, Hurrell MA, Barber PA, Ranta A, Fink JN, Le Heron C. Increased Large Vessel Occlusive Strokes After the Christchurch March 15, 2019, Terror Attack. Neurology 2020; 96:171-174. [PMID: 33310879 DOI: 10.1212/wnl.0000000000011341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/12/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Teddy Y Wu
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand.
| | - Daniel Myall
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - David Palmer
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - James Beharry
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - Jen Yuh Lim
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - Deborah F Mason
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - Jon Reimers
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - Roderick Duncan
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - James Weaver
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - Wayne Collecutt
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - Paul Mouthaan
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - Anthony Lim
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - Mike A Hurrell
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - P Alan Barber
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - Annemarei Ranta
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - John N Fink
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
| | - Campbell Le Heron
- From the Department of Neurology (T.Y.W., D.P., J.B., J.Y.L., D.F.M., J.R., R.D., J.N.F., C.L.H.), Christchurch Hospital; New Zealand Brain Research Institute (T.Y.W., D.M., D.F.M., C.L.H.), Christchurch; Emergency Department (J.W.), Christchurch Hospital; Department of Radiology (W.C., P.M., A.L., M.A.H.), Christchurch Hospital; Department of Neurology (P.A.B.), Auckland City Hospital; and Department of Neurology (A.R.), Wellington Regional Hospital, New Zealand
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Tarkanyi G, Csecsei P, Szegedi I, Feher E, Annus A, Molnar T, Szapary L. Detailed severity assessment of Cincinnati Prehospital Stroke Scale to detect large vessel occlusion in acute ischemic stroke. BMC Emerg Med 2020; 20:64. [PMID: 32831019 PMCID: PMC7446055 DOI: 10.1186/s12873-020-00360-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/17/2020] [Indexed: 11/10/2022] Open
Abstract
Background Selecting stroke patients with large vessel occlusion (LVO) based on prehospital stroke scales could provide a faster triage and transportation to a comprehensive stroke centre resulting a favourable outcome. We aimed here to explore the detailed severity assessment of Cincinnati Prehospital Stroke Scale (CPSS) to improve its ability to detect LVO in acute ischemic stroke (AIS) patients. Methods A cross-sectional analysis was performed in a prospectively collected registry of consecutive patients with first ever AIS admitted within 6 h after symptom onset. On admission stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) and the presence of LVO was confirmed by computed tomography angiography (CTA) as an endpoint. A detailed version of CPSS (d-CPSS) was designed based on the severity assessment of CPSS items derived from NIHSS. The ability of this scale to confirm an LVO was compared to CPSS and NIHSS respectively. Results Using a ROC analysis, the AUC value of d-CPSS was significantly higher compared to the AUC value of CPSS itself (0.788 vs. 0.633, p < 0.001) and very similar to the AUC of NIHSS (0.795, p = 0.510). An optimal cut-off score was found as d-CPSS≥5 to discriminate the presence of LVO (sensitivity: 69.9%, specificity: 75.2%). Conclusion A detailed severity assessment of CPSS items (upper extremity weakness, facial palsy and speech disturbance) could significantly increase the ability of CPSS to discriminate the presence of LVO in AIS patients.
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Affiliation(s)
- Gabor Tarkanyi
- Department of Neurology, University of Pecs, 13 Ifjusag utja, Pecs, 7624, Hungary
| | - Peter Csecsei
- Department of Neurology, University of Pecs, 13 Ifjusag utja, Pecs, 7624, Hungary
| | - Istvan Szegedi
- Department of Neurology, University of Debrecen, Debrecen, Hungary
| | - Evelin Feher
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Adam Annus
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Tihamer Molnar
- Department of Anaesthesiology and Intensive Therapy, University of Pecs, Pecs, Hungary
| | - Laszlo Szapary
- Department of Neurology, University of Pecs, 13 Ifjusag utja, Pecs, 7624, Hungary.
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Csecsei P, Tarkanyi G, Bosnyak E, Szapary L, Lenzser G, Szolics A, Buki A, Hegyi P, Abada A, Molnar T. Risk analysis of post-procedural intracranial hemorrhage based on STAY ALIVE Acute Stroke Registry. J Stroke Cerebrovasc Dis 2020; 29:104851. [PMID: 32402722 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104851] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/24/2020] [Accepted: 03/28/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Intracranial hemorrhages (ICH) are classified as symptomatic or asymptomatic according to the presence of clinical deterioration. Here, we aimed to find predictive factors of symptomatic intracranial bleeding in a registry-based stroke research. METHODS Data of consecutive patients with acute ischemic stroke (AIS) were extracted from the prospective STAY ALIVE stroke registry. Analysis of the total population and treatment sugroups such as endovascular thrombectomy (EVT), intravenous thrombolysis (IVT), or their combination (IVT+EVT) were also done. Outcome measures were ICH, 30- and 90-day clinical outcome based on the modified Rankin Scale (mRS:0-2 as favorable outcome). The hemorrhage was captured by a non-enhanced CT of the skull within 24 h after procedure. RESULTS A total of 355 patients (mean age: 68±11; female N=177 (49.9%); EVT n=131 (36.9%); IVT n=157 (44.2%); IVT+EVT n=67 (18.9%) were included in the analysis. The total number of ICH was 47 (13%), symptomatic (sICH) 12 (3.4%) and asymptomatic (aICH) 35 (9.9%) in the whole population. NIHSS ≥15.5 at 24 post stroke hours predicted sICH with a sensitivity of 100% and a specificity of 92% (p<0.001). Furthermore, lower age, good collateral circulation on initial CT angiography and lower NIHSS score measured at 24 h independently associated with a favorable 90-day outcome, whereas baseline NIHSS and ASPECT score were not. CONCLUSION Although partial recanalization, ASPECT< 6, and poor collaterals were significantly associated with sICH, the only independent predictor was NIHSS ≥15.5 at 24 post stroke hours. This suggests a careful evaluation of patients with worsening NIHSS despite an adequate therapy.
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Affiliation(s)
- Peter Csecsei
- Department of Neurology, University of Pecs, Medical School, Ifjusag u. 13., Pecs 7623, Hungary.
| | - Gabor Tarkanyi
- Department of Neurology, University of Pecs, Medical School, Ifjusag u. 13., Pecs 7623, Hungary
| | - Edit Bosnyak
- Department of Neurology, University of Pecs, Medical School, Ifjusag u. 13., Pecs 7623, Hungary
| | - Laszlo Szapary
- Department of Neurology, University of Pecs, Medical School, Ifjusag u. 13., Pecs 7623, Hungary
| | - Gabor Lenzser
- Department of Neurosurgery, University of Pecs, Medical School, Pecs, Hungary
| | - Alex Szolics
- Department of Neurosurgery, University of Pecs, Medical School, Pecs, Hungary
| | - Andras Buki
- Department of Neurosurgery, University of Pecs, Medical School, Pecs, Hungary
| | - Peter Hegyi
- Institute for Translational Medicine, University of Pecs, Medical School, Pecs, Hungary
| | - Alan Abada
- Department of Anaesthesiology and Intensive Care, University of Pecs, Medical School, Pecs, Hungary
| | - Tihamer Molnar
- Department of Anaesthesiology and Intensive Care, University of Pecs, Medical School, Pecs, Hungary
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Rennert RC, Wali AR, Steinberg JA, Santiago-Dieppa DR, Olson SE, Pannell JS, Khalessi AA. Epidemiology, Natural History, and Clinical Presentation of Large Vessel Ischemic Stroke. Neurosurgery 2020; 85:S4-S8. [PMID: 31197329 PMCID: PMC6584910 DOI: 10.1093/neuros/nyz042] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 01/27/2019] [Indexed: 01/01/2023] Open
Abstract
Large vessel occlusions (LVOs), variably defined as blockages of the proximal intracranial anterior and posterior circulation, account for approximately 24% to 46% of acute ischemic strokes. Commonly refractory to intravenous tissue plasminogen activator (tPA), LVOs place large cerebral territories at ischemic risk and cause high rates of morbidity and mortality without further treatment. Over the past few years, an abundance of high-quality data has demonstrated the efficacy of endovascular thrombectomy for improving clinical outcomes in patients with LVOs, transforming the treatment algorithm for affected patients. In this review, we discuss the epidemiology, pathophysiology, natural history, and clinical presentation of LVOs as a framework for understanding the recent clinical strides of the endovascular era.
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Affiliation(s)
- Robert C Rennert
- Department of Neurosurgery, University of California-San Diego, La Jolla, California
| | - Arvin R Wali
- Department of Neurosurgery, University of California-San Diego, La Jolla, California
| | - Jeffrey A Steinberg
- Department of Neurosurgery, University of California-San Diego, La Jolla, California
| | | | - Scott E Olson
- Department of Neurosurgery, University of California-San Diego, La Jolla, California
| | - J Scott Pannell
- Department of Neurosurgery, University of California-San Diego, La Jolla, California
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California-San Diego, La Jolla, California
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Rodríguez-Pardo J, Riera-López N, Fuentes B, Alonso de Leciñana M, Secades-García S, Álvarez-Fraga J, Busca-Ostolaza P, Carneado-Ruiz J, Díaz-Guzmán J, Egido-Herrero J, Gil-Núñez A, Masjuan-Vallejo J, Real-Martínez V, Vivancos-Mora J, Díez-Tejedor E. Prehospital selection of thrombectomy candidates beyond large vessel occlusion. Neurology 2020; 94:e851-e860. [DOI: 10.1212/wnl.0000000000008998] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 09/02/2019] [Indexed: 11/15/2022] Open
Abstract
ObjectiveCurrent prehospital scales used to detect large vessel occlusion reveal very low endovascular thrombectomy (EVT) rates among selected patients. We developed a novel prehospital scale, the Madrid-Direct Referral to Endovascular Center (M-DIRECT), to identify EVT candidates for direct transfer to EVT-capable centers (EVT-Cs). The scale evaluated clinical examination, systolic blood pressure, and age. Since March 2017, patients closer to a stroke unit without EVT capabilities and an M-DIRECT positive score have been transferred to the nearest EVT-C. To test the performance of the scale-based routing protocol, we compared its outcomes with those of a simultaneous cohort of patients directly transferred to an EVT-C.MethodsIn this prospective observational study of consecutive patients with stroke code seen by emergency medical services, we compared diagnoses, treatments, and outcomes of patients who were closer to an EVT-C (mothership cohort) with those transferred according to the M-DIRECT score (M-DIRECT cohort).ResultsThe M-DIRECT cohort included 327 patients and the mothership cohort 214 patients. In the M-DIRECT cohort, 227 patients were negative and 100 were positive. Twenty-four (10.6%) patients required secondary transfer, leaving 124 (38%) patients from the M-DIRECT cohort admitted to an EVT-C. EVT rates were similar for patients with ischemic stroke in both cohorts (30.9% vs 31.5%). The M-DIRECT scale had 79% sensitivity, 82% specificity, and 53% positive predictive value for EVT. Recanalization and independence rates at 3 months did not differ between the cohorts.ConclusionsThe M-DIRECT scale was highly accurate for EVT, with treatment rates and outcomes similar to those of a mothership paradigm, thereby avoiding EVT-C overload with a low rate of secondary transfers.
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Hendrix P, Sofoluke N, Adams MD, Kunaprayoon S, Zand R, Kolinovsky AN, Person TN, Gupta M, Goren O, Schirmer CM, Rost NS, Faber JE, Griessenauer CJ. Risk Factors for Acute Ischemic Stroke Caused by Anterior Large Vessel Occlusion. Stroke 2020; 50:1074-1080. [PMID: 31009355 DOI: 10.1161/strokeaha.118.023917] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background and Purpose- Accurate prediction of acute ischemic stroke (AIS) caused by anterior large vessel occlusion (LVO) that is amendable to mechanical thrombectomy remains a challenge. We developed and validated a prediction model for anterior circulation LVO stroke using past medical history elements present on admission and neurological examination. Methods- We retrospectively reviewed AIS patients admitted between 2009 and 2017 to 3 hospitals within a large healthcare system in the United States. Patients with occlusions of the internal carotid artery or M1 or M2 segments of the middle cerebral artery were randomly split into 2/3 derivation and 1/3 validation cohorts for development of an anterior circulation LVO prediction model and score that was further curtailed for potential use in the prehospital setting. Results- A total of 1654 AIS were reviewed, including 248 (15%) with proximal anterior circulation LVO AIS. In the derivation cohort, National Institutes of Health Stroke Scale score at the time of cerebrovascular imaging, current smoking status, type 2 diabetes mellitus, extracranial carotid, and intracranial atherosclerotic stenosis was significantly associated with anterior circulation LVO stroke. The prehospital score was curtailed to National Institutes of Health Stroke Scale score, current smoking status, and type 2 diabetes mellitus. The areas under the curve for the prediction model, prehospital score, and National Institutes of Health Stroke Scale score alone were 0.796, 0.757, and 0.725 for the derivation cohort and 0.770, 0.689, and 0.665 for the validation cohort, respectively. The Youden index J was 0.46 for a score of >6 with 84.7% sensitivity and 62.0% specificity for the prediction model. Conclusions- Previously reported LVO stroke prediction scores focus solely on elements of the neurological examination. In addition to stroke severity, smoking, diabetes mellitus, extracranial carotid, and intracranial atherosclerotic stenosis were associated with anterior circulation LVO AIS. Although atherosclerotic stenosis may not be known until imaging is obtained, smoking and diabetes mellitus history can be readily obtained in the field and represent important elements of the prehospital score supplementing National Institutes of Health Stroke Scale score.
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Affiliation(s)
- Philipp Hendrix
- From the Department of Neurosurgery (P.H., N.S., O.G., C.M.S., C.J.G.), Geisinger, Danville, PA.,Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany (P.H.)
| | - Nelson Sofoluke
- From the Department of Neurosurgery (P.H., N.S., O.G., C.M.S., C.J.G.), Geisinger, Danville, PA
| | - Matthew D Adams
- Geisinger Commonwealth School of Medicine, Scranton, PA (M.D.A., S.K.)
| | - Saran Kunaprayoon
- Geisinger Commonwealth School of Medicine, Scranton, PA (M.D.A., S.K.)
| | - Ramin Zand
- Department of Neurology (R.Z.), Geisinger, Danville, PA
| | - Amy N Kolinovsky
- Geisinger Health System Phenomic Analytics and Clinical Data Core, Danville, PA (A.N.K., T.N.P., M.G.)
| | - Thomas N Person
- Geisinger Health System Phenomic Analytics and Clinical Data Core, Danville, PA (A.N.K., T.N.P., M.G.)
| | - Mudit Gupta
- Geisinger Health System Phenomic Analytics and Clinical Data Core, Danville, PA (A.N.K., T.N.P., M.G.)
| | - Oded Goren
- From the Department of Neurosurgery (P.H., N.S., O.G., C.M.S., C.J.G.), Geisinger, Danville, PA
| | - Clemens M Schirmer
- From the Department of Neurosurgery (P.H., N.S., O.G., C.M.S., C.J.G.), Geisinger, Danville, PA
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (N.S.R.)
| | - James E Faber
- Department of Cell Biology and Physiology, University of North Carolina, Chapel Hill (J.E.F.)
| | - Christoph J Griessenauer
- From the Department of Neurosurgery (P.H., N.S., O.G., C.M.S., C.J.G.), Geisinger, Danville, PA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria (C.J.G.)
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Grewal P, Lahoti S, Aroor S, Snyder K, Pettigrew LC, Goldstein LB. Effect of Known Atrial Fibrillation and Anticoagulation Status on the Prehospital Identification of Large Vessel Occlusion. J Stroke Cerebrovasc Dis 2019; 28:104404. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 09/08/2019] [Indexed: 10/25/2022] Open
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Xin-Ji-Er-Kang Alleviates Myocardial Infarction-Induced Cardiovascular Remodeling in Rats by Inhibiting Endothelial Dysfunction. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4794082. [PMID: 31341899 PMCID: PMC6614977 DOI: 10.1155/2019/4794082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/29/2019] [Accepted: 05/26/2019] [Indexed: 12/17/2022]
Abstract
The present study was designed to elucidate the beneficial effects of XJEK on myocardial infarction (MI) in rats, especially through the amelioration of endothelial dysfunction (ED). 136 Sprague-Dawley rats were randomized into 13 groups: control group for 0wk (n = 8); sham groups for 2, 4, and 6 weeks (wk); MI groups for 2, 4, and 6 wk; MI+XJEK groups for 2, 4, and 6w k; MI+Fosinopril groups for 2, 4, and 6 wk (n = 8~10). In addition, 8 rats were treated for Evans blue staining and Tetrazolium chloride (TTC) staining to determine the infarct size. Cardiac function, ECG, and cardiac morphological changes were examined. Colorimetric analysis was employed to detect nitric oxide (NO), and enzyme-linked immunosorbent assay (ELISA) was applied to determine N-terminal probrain natriuretic peptide (NT-ProBNP), endothelin-1 (ET-1), angiotensin II (Ang II), asymmetric dimethylarginine (ADMA), tetrahydrobiopterin (BH4), and endothelial NO synthase (eNOS) content. The total eNOS and eNOS dimer/(dimer+monomer) ratios in cardiac tissues were detected by Western blot. We found that administration of XJEK markedly ameliorated cardiovascular remodeling (CR), which was manifested by decreased HW/BW ratio, CSA, and less collagen deposition after MI. XJEK administration also improved cardiac function by significant inhibition of the increased hemodynamic parameters in the early stage and by suppression of the decreased hemodynamic parameters later on. XJEK also continuously suppressed the increased NT-ProBNP content in the serum of MI rats. XJEK improved ED with stimulated eNOS activities, as well as upregulated NO levels, BH4 content, and eNOS dimer/(dimer+monomer) ratio in the cardiac tissues. XJEK downregulated ET-1, Ang II, and ADMA content obviously compared to sham group. In conclusion, XJEK may exert the protective effects on MI rats and could continuously ameliorate ED and reverse CR with the progression of MI over time.
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Narwal P, Chang AD, Grory BM, Jayaraman M, Madsen T, Paolucci G, Cutting S, Burton T, Dakay K, Schomer A, Rostanski S, Noorian AR, Nour M, Liebeskind DS, Saver J, Furie K, Yaghi S. The Addition of Atrial Fibrillation to the Los Angeles Motor Scale May Improve Prediction of Large Vessel Occlusion. J Neuroimaging 2019; 29:463-466. [PMID: 30900276 DOI: 10.1111/jon.12613] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/07/2019] [Accepted: 03/13/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE There is evidence suggesting that Los Angeles Motor Scale (LAMS) ≥ 4 predicts large vessel occlusion (LVO). We aim to determine whether atrial fibrillation (AF) can improve the ability of LAMS in predicting LVO. METHODS We included consecutive patients with a discharge diagnosis of ischemic stroke admitted within 24 hours from last known normal time who underwent emergent vascular imaging using a computerized tomography angiography (CTA) of the head and neck. LVO was defined as intracranial internal carotid artery, proximal middle cerebral artery (M1 or proximal M2 segment), or basilar occlusion. LAMS was determined in the emergency department upon arrival. Univariate and multivariable models were performed to identify predictors of LVO and to determine whether AF improves the ability of LAMS to predict LVO. RESULTS Among 1,234 patients admitted with ischemic stroke, 862 underwent emergent vascular imaging (69.8%) out of which 374 (43.4%) had evidence of LVO and 207 (24%) underwent mechanical thrombectomy. In multivariable models, predictors of LVO were LAMS (OR 1.42 per one point increase 95% CI 1.29-1.57) and AF (OR 1.95 95% CI 1.26-3.02, P < .001). We developed the LAMS-AF that includes the LAMS score and adds two points if AF is present. In this analysis, LAMS-AF (AUC .78) had improved prediction over LAMS (AUC .76) in predicting LVO and lead to reclassification of 8/68 patients (11.8%) with LAMS = 3 group into the high-risk LVO group. CONCLUSION In patients with LAMS = 3, using the LAMS-AF score may improve the ability of LAMS in predicting LVO. Larger studies are needed to confirm our findings.
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Affiliation(s)
| | | | | | | | - Tracy Madsen
- Emergency Medicine, Brown Medical School, Providence, RI
| | | | | | | | | | | | - Sara Rostanski
- Department of Neurology, New York Medical School, New York, NY
| | - Ali Reza Noorian
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA
| | - May Nour
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA
| | - David S Liebeskind
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA
| | - Jeffrey Saver
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA
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Chang A, Ricci B, Grory BM, Cutting S, Burton T, Dakay K, Jayaraman M, Merkler A, Reznik M, Lerario MP, Song C, Kamel H, Elkind MSV, Furie K, Yaghi S. Cardiac Biomarkers Predict Large Vessel Occlusion in Patients with Ischemic Stroke. J Stroke Cerebrovasc Dis 2019; 28:1726-1731. [PMID: 30898447 DOI: 10.1016/j.jstrokecerebrovasdis.2019.02.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND PURPOSE Cardiac biomarkers may help identify stroke mechanisms and may aid in improving stroke prevention strategies. There is limited data on the association between these biomarkers and acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). We hypothesized that cardiac biomarkers (cardiac troponin and left atrial diameter [LAD]) would be associated with the presence of LVO. METHODS Data were abstracted from a single center prospective AIS database over 18 months and included all patients with AIS with CT angiography of the head and neck. The presence of LVO was defined as proximal LVO of the internal carotid artery terminus, middle cerebral artery (M1 or proximal M2), or basilar artery. Univariate analyses and predefined multivariable models were performed to determine the association between cardiac biomarkers (positive troponin [troponin ≥0.1 ng/mL] and LAD on transthoracic echocardiogram) and LVO adjusting for demographic factors (age and sex), risk factors (hypertension, diabetes, hyperlipidemia, history of stroke, congestive heart failure, coronary heart disease, and smoking), and atrial fibrillation (AF). RESULTS We identified 1234 patients admitted with AIS; 886 patients (71.8%) had vascular imaging to detect LVO. Of those with imaging available, 374 patients (42.2%) had LVO and 207 patients (23.4%) underwent thrombectomy. There was an association between positive troponin and LVO after adjusting for age, sex and other risk factors (adjusted OR 1.69 [1.08-2.63], P = .022) and this association persisted after including AF in the model (adjusted OR 1.60 [1.02-2.53], P = 0.043). There was an association between LAD and LVO after adjusting for age, sex, and risk factors (adjusted OR per mm 1.03 [1.01-1.05], P = 0.013) but this association was not present when AF was added to the model (adjusted OR 1.01 [0.99-1.04], P = .346). Sensitivity analyses using thrombectomy as an outcome yielded similar findings. CONCLUSIONS Cardiac biomarkers, particularly serum troponin levels, are associated with acute LVO in patients with ischemic stroke. Prospective studies are ongoing to confirm this association and to test whether anticoagulation reduces the risk of recurrent embolism in this patient population.
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Affiliation(s)
- Andrew Chang
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Brittany Ricci
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Brian Mac Grory
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Shawna Cutting
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Tina Burton
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Katarina Dakay
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Mahesh Jayaraman
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island; Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island; Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Alexander Merkler
- Departments of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, New York
| | - Michael Reznik
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael P Lerario
- Departments of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, New York
| | - Christopher Song
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Hooman Kamel
- Departments of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, New York
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Karen Furie
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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Naylor J, Thevathasan A, Churilov L, Guo R, Xiong Y, Koome M, Chen Z, Chen Z, Liu X, Kwan P, Campbell BCV. Association between different acute stroke therapies and development of post stroke seizures. BMC Neurol 2018; 18:61. [PMID: 29724190 PMCID: PMC5932812 DOI: 10.1186/s12883-018-1064-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 04/26/2018] [Indexed: 12/22/2022] Open
Abstract
Background Epilepsy is a major complication of stroke. We aimed to establish whether there is an association between intravenous thrombolysis, intra-arterial thrombolysis and post stroke seizure (PSS) development. Improved understanding of the relationship between reperfusion therapies and seizure development may improve post-stroke monitoring and follow-up. Methods This was a retrospective, multicentre cohort study conducted at the Royal Melbourne Hospital and Jingling Hospital Nanjing. We included patients with anterior circulation ischemic stroke admitted 2008–2015. Patients were divided into four treatment groups 1. IV-tPA only, 2. Intra-arterial therapies (IAT) only, 3. IAT + IV-tPA and 4. stroke unit care only (i.e. no IV-tPA or IAT). To assess the association between type of reperfusion treatment and seizure incidence we used multivariable logistic regression models adjusted for age, stroke severity, 3-month functional outcome and prognostic factors. Results There were 1375 stroke unit care-only patients, of whom 28 (2%) developed PSS. There were 363 patients who received only IV-tPA, of whom 21 (5.8%) developed PSS. There were 93 patients who received IAT only, of whom 12 (12.9%) developed PSS and 112 that received both IV-tPA + IAT, of which 5 (4.5%) developed PSS. All reperfusion treatments were associated with seizure development compared to stroke unit care-only patients: IV-tPA only adjusted odds ratio (aOR) 3.7, 95%CI 1.8–7.4, p < 0.0001; IAT aOR 5.5, 95%CI 2.1–14.3, p < 0.0001, IAT + IV-tPA aOR 3.4, 95% CI 0.98–11.8, p = 0.05. These aORs did not differ significantly between treatment groups (IV-tPA + IAT versus IV-tPA p = 0.89, IV-tPA + IAT versus IAT, p = 0.44). Conclusions Patients receiving thrombolytic or intra-arterial reperfusion therapies for acute ischemic stroke are at higher risk of epilepsy and may benefit from longer follow-up. No evidence for an additive or synergistic effect of treatment modality on seizure development was found. Electronic supplementary material The online version of this article (10.1186/s12883-018-1064-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jillian Naylor
- Melbourne Brain Centre, Royal Melbourne Hospital and Department of Neurology, University of Melbourne, Parkville, Melbourne, Australia. .,Department of Neurology, Royal Melbourne Hospital, Parkville, VIC, 3050, Australia.
| | - Arthur Thevathasan
- Melbourne Brain Centre, Royal Melbourne Hospital and Department of Neurology, University of Melbourne, Parkville, Melbourne, Australia
| | - Leonid Churilov
- The Florey Institute of Neuroscience and Mental Heath, University of Melbourne, Parkville, Melbourne, Australia
| | - Ruibing Guo
- Department of Neurology, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yunyun Xiong
- Department of Neurology, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Miriam Koome
- Melbourne Brain Centre, Royal Melbourne Hospital and Department of Neurology, University of Melbourne, Parkville, Melbourne, Australia
| | - Ziyi Chen
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ziyuan Chen
- Melbourne Brain Centre, Royal Melbourne Hospital and Department of Neurology, University of Melbourne, Parkville, Melbourne, Australia
| | - Xinfeng Liu
- Department of Neurology, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Patrick Kwan
- Melbourne Brain Centre, Royal Melbourne Hospital and Department of Neurology, University of Melbourne, Parkville, Melbourne, Australia
| | - Bruce C V Campbell
- Melbourne Brain Centre, Royal Melbourne Hospital and Department of Neurology, University of Melbourne, Parkville, Melbourne, Australia
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