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Younger DS. Motor sequela of adult and pediatric stroke: Imminent losses and ultimate gains. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:305-346. [PMID: 37620077 DOI: 10.1016/b978-0-323-98817-9.00025-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Stroke is the leading cause of neurological disability in the United States and worldwide. Remarkable advances have been made over the past 20 years in acute vascular treatments to reduce infarct size and improve neurological outcome. Substantially less progress has been made in the understanding and clinical approaches to neurological recovery after stroke. This chapter reviews the epidemiology, bedside examination, localization approaches, and classification of stroke, with an emphasis on motor stroke presentations and management, and promising research approaches to enhancing motor aspects of stroke recovery.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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2
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Pharmacological Strategies for Stroke Intervention: Assessment of Pathophysiological Relevance and Clinical Trials. Clin Neuropharmacol 2023; 46:17-30. [PMID: 36515293 DOI: 10.1097/wnf.0000000000000534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The present review describes stroke pathophysiology in brief and discusses the spectrum of available treatments with different promising interventions that are in clinical settings or are in clinical trials. METHODS Relevant articles were searched using Google Scholar, Cochrane Library, and PubMed. Keywords for the search included ischemic stroke, mechanisms, stroke interventions, clinical trials, and stem cell therapy. RESULTS AND CONCLUSION Stroke accounts to a high burden of mortality and morbidity around the globe. Time is an important factor in treating stroke. Treatment options are limited; however, agents with considerable efficacy and tolerability are being continuously explored. With the advances in stroke interventions, new therapies are being formulated with a hope that these may aid the ongoing protective and reparative processes. Such therapies may have an extended therapeutic time window in hours, days, weeks, or longer and may have the advantage to be accessible by a majority of the patients.
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Pilgram-Pastor SM, Piechowiak EI, Dobrocky T, Kaesmacher J, Den Hollander J, Gralla J, Mordasini P. Stroke thrombectomy complication management. J Neurointerv Surg 2021; 13:912-917. [PMID: 34158401 PMCID: PMC8458081 DOI: 10.1136/neurintsurg-2021-017349] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/11/2021] [Indexed: 11/04/2022]
Abstract
Endovascular mechanical thrombectomy (EVT) is widely accepted as the first-line treatment for acute ischemic stroke in patients with large vessel occlusion. Being an invasive treatment, this method is associated with various preoperative, perioperative, and postoperative complications. These complications may influence peri-interventional morbidity and mortality and therefore treatment efficacy and clinical outcome. The aim of this review is to discuss the most common types of complications associated with EVT, the probable mechanisms of injury, and effective methods to manage and prevent complications.
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Affiliation(s)
- Sara M Pilgram-Pastor
- Department for Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Eike I Piechowiak
- Department for Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Department for Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Department for Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Juergen Den Hollander
- Department for Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Jan Gralla
- Department for Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department for Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland
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Etherton MR, Barreto AD, Schwamm LH, Wu O. Neuroimaging Paradigms to Identify Patients for Reperfusion Therapy in Stroke of Unknown Onset. Front Neurol 2018; 9:327. [PMID: 29867736 PMCID: PMC5962731 DOI: 10.3389/fneur.2018.00327] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/25/2018] [Indexed: 12/17/2022] Open
Abstract
Despite the proven efficacy of intravenous alteplase or endovascular thrombectomy for the treatment of patients with acute ischemic stroke, only a minority receive these treatments. This low treatment rate is due in large part to delay in hospital arrival or uncertainty as to the exact time of onset of ischemic stroke, which renders patients outside the current guideline-recommended window of eligibility for receiving these therapeutics. However, recent pivotal clinical trials of late-window thrombectomy now force us to rethink the value of a simplistic chronological formulation that “time is brain.” We must recognize a more nuanced concept that the rate of tissue death as a function of time is not invariant, that still salvageable tissue at risk of infarction may be present up to 24 h after last-known well, and that those patients may strongly benefit from reperfusion. Multiple studies have sought to address this clinical dilemma using neuroimaging methods to identify a radiographic time-stamp of stroke onset or evidence of salvageable ischemic tissue and thereby increase the number of patients eligible for reperfusion therapies. In this review, we provide a critical analysis of the current state of neuroimaging techniques to select patients with unwitnessed stroke for revascularization therapies and speculate on the future direction of this clinically relevant area of stroke research.
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Affiliation(s)
- Mark R Etherton
- Department of Neurology, JPK Stroke Research Center, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, MA, United States
| | - Andrew D Barreto
- Stroke Division, Department of Neurology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Lee H Schwamm
- Department of Neurology, JPK Stroke Research Center, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, MA, United States
| | - Ona Wu
- Department of Neurology, JPK Stroke Research Center, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, MA, United States.,Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Charlestown, MA, United States
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5
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Sung SM, Lee TH, Cho HJ, Cho GY, Jung DS, Lee JI, Ko JK, Yip S. Clinical predictors for favorable outcomes from endovascular recanalization in wake-up stroke. J Clin Neurosci 2017; 41:66-70. [DOI: 10.1016/j.jocn.2017.02.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 02/10/2017] [Indexed: 10/20/2022]
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Ginsberg MD. Expanding the concept of neuroprotection for acute ischemic stroke: The pivotal roles of reperfusion and the collateral circulation. Prog Neurobiol 2016; 145-146:46-77. [PMID: 27637159 DOI: 10.1016/j.pneurobio.2016.09.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/22/2016] [Accepted: 09/10/2016] [Indexed: 12/27/2022]
Abstract
This review surveys the efforts taken to achieve clinically efficacious protection of the ischemic brain and underscores the necessity of expanding our purview to include the essential role of cerebral perfusion and the collateral circulation. We consider the development of quantitative strategies to measure cerebral perfusion at the regional and local levels and the application of these methods to elucidate flow-related thresholds of ischemic viability and to characterize the ischemic penumbra. We stress that the modern concept of neuroprotection must consider perfusion, the necessary substrate upon which ischemic brain survival depends. We survey the major mechanistic approaches to neuroprotection and review clinical neuroprotection trials, focusing on those phase 3 multicenter clinical trials for acute ischemic stroke that have been completed or terminated. We review the evolution of thrombolytic therapies; consider the lessons learned from the initial, negative multicenter trials of endovascular therapy; and emphasize the highly successful positive trials that have finally established a clinical role for endovascular clot removal. As these studies point to the brain's collateral circulation as key to successful reperfusion, we next review the anatomy and pathophysiology of collateral perfusion as it relates to ischemic infarction, as well as the molecular and genetic influences on collateral development. We discuss the current MR and CT-based diagnostic methods for assessing the collateral circulation and the prognostic significance of collaterals in ischemic stroke, and we consider past and possible future therapeutic directions.
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Affiliation(s)
- Myron D Ginsberg
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, United States.
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7
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Johnston JC, Wester K, Sartwelle TP. Neurological Fallacies Leading to Malpractice: A Case Studies Approach. Neurol Clin 2016; 34:747-73. [PMID: 27445252 DOI: 10.1016/j.ncl.2016.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A young woman presents with an intracranial arachnoid cyst. Another is diagnosed with migraine headache. An elderly man awakens with a stroke. And a baby delivered vaginally after 2 hours of questionable electronic fetal monitoring patterns grows up to have cerebral palsy. These seemingly disparate cases share a common underlying theme: medical myths. Myths that may lead not only to misdiagnosis and treatment harms but to seemingly never-ending medical malpractice lawsuits, potentially culminating in a settlement or judgment against an unsuspecting neurologist. This article provides a case studies approach exposing the fallacies and highlighting proper management of these common neurologic presentations.
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Affiliation(s)
- James C Johnston
- Legal Medicine Consultants, 1150 N Loop 1604 West, Suite 108-625, San Antonio, TX 78248, USA.
| | - Knut Wester
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Bergen 5021, Norway
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Abstract
BACKGROUND We studied the safety of use of acute reperfusion therapies in patients with stroke- on- awakening using a computed tomographic angiography (Cta) based large vessel occlusion-good scan paradigm in clinical routine. METHODS the Cta database of the Calgary stroke program was reviewed for the period January 2003-March 2010. patients with stroke-on-awakening with large artery occlusions on Cta, who received conservative, iV thrombolytic and/or endovascular treatment at discretion of the attending stroke neurologist were analyzed. time of onset was defined by the time last seen or known to be normal. Baseline non-contrast Ct scan (nCCt) alberta Stroke program early Ct Score (aSpeCtS) > 7 was considered a good scan. hemorrhage was defined on follow-up brain imaging using eCaSS 3 criteria. independence (mrS≤2) at three months was considered a good clinical outcome. Standard descriptive statistics and multivariable analysis were done. RESULTS among 532 patients with large artery occlusions, 70 patients with stroke-on-awakening (13.1%) were identified. the median age was 69.5 (iQr 24) and 41 (58.6%) were female; 41 (58.6%) received anti-platelets only and 29 (41.4%) received thrombolytic treatment [iV-12 (17.1%), iV/ia-12 (17.1%) and ia-5(7.1%)]. unadjusted analysis showed that baseline nCCt aSpeCtS ≤ 7 (p=0.002) and higher nihSS scores (p=0.018) were associated with worse outcomes. there were no ph2 hemorrhages in the iV thrombolytic or endovascular treated group. functional outcome was not different by treatment. CONCLUSION When carefully selected using Ct –Cta, by a good scan (aSpeCtS > 7) occlusion paradigm, acute reperfusion therapies in patients with stroke-on-awakening can be performed safely in clinical routine.
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Lu Y, Wang J, Huang R, Chen G, Zhong L, Shen S, Zhang C, Li X, Cao S, Liao W, Liao Y, Bin J. Microbubble-Mediated Sonothrombolysis Improves Outcome After Thrombotic Microembolism-Induced Acute Ischemic Stroke. Stroke 2016; 47:1344-53. [PMID: 27048701 DOI: 10.1161/strokeaha.115.012056] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 03/04/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Yongkang Lu
- From the State Key Laboratory of Organ Failure Research, Department of Cardiology (Y. Lu, J.W., R.H., G.C., L.Z., S.S., C.Z., X.L., S.C., Y. Liao, J.B.) and Department of Oncology (W.L.), Nanfang Hospital, Southern Medical University, Guangzhou, China; and Department of Cardiology, the 458th Hospital of the Chinese People’s Liberation Army, Guangzhou, China (R.H.)
| | - Junfen Wang
- From the State Key Laboratory of Organ Failure Research, Department of Cardiology (Y. Lu, J.W., R.H., G.C., L.Z., S.S., C.Z., X.L., S.C., Y. Liao, J.B.) and Department of Oncology (W.L.), Nanfang Hospital, Southern Medical University, Guangzhou, China; and Department of Cardiology, the 458th Hospital of the Chinese People’s Liberation Army, Guangzhou, China (R.H.)
| | - Ruizhu Huang
- From the State Key Laboratory of Organ Failure Research, Department of Cardiology (Y. Lu, J.W., R.H., G.C., L.Z., S.S., C.Z., X.L., S.C., Y. Liao, J.B.) and Department of Oncology (W.L.), Nanfang Hospital, Southern Medical University, Guangzhou, China; and Department of Cardiology, the 458th Hospital of the Chinese People’s Liberation Army, Guangzhou, China (R.H.)
| | - Gangbin Chen
- From the State Key Laboratory of Organ Failure Research, Department of Cardiology (Y. Lu, J.W., R.H., G.C., L.Z., S.S., C.Z., X.L., S.C., Y. Liao, J.B.) and Department of Oncology (W.L.), Nanfang Hospital, Southern Medical University, Guangzhou, China; and Department of Cardiology, the 458th Hospital of the Chinese People’s Liberation Army, Guangzhou, China (R.H.)
| | - Lintao Zhong
- From the State Key Laboratory of Organ Failure Research, Department of Cardiology (Y. Lu, J.W., R.H., G.C., L.Z., S.S., C.Z., X.L., S.C., Y. Liao, J.B.) and Department of Oncology (W.L.), Nanfang Hospital, Southern Medical University, Guangzhou, China; and Department of Cardiology, the 458th Hospital of the Chinese People’s Liberation Army, Guangzhou, China (R.H.)
| | - Shuxin Shen
- From the State Key Laboratory of Organ Failure Research, Department of Cardiology (Y. Lu, J.W., R.H., G.C., L.Z., S.S., C.Z., X.L., S.C., Y. Liao, J.B.) and Department of Oncology (W.L.), Nanfang Hospital, Southern Medical University, Guangzhou, China; and Department of Cardiology, the 458th Hospital of the Chinese People’s Liberation Army, Guangzhou, China (R.H.)
| | - Chuanxi Zhang
- From the State Key Laboratory of Organ Failure Research, Department of Cardiology (Y. Lu, J.W., R.H., G.C., L.Z., S.S., C.Z., X.L., S.C., Y. Liao, J.B.) and Department of Oncology (W.L.), Nanfang Hospital, Southern Medical University, Guangzhou, China; and Department of Cardiology, the 458th Hospital of the Chinese People’s Liberation Army, Guangzhou, China (R.H.)
| | - Xinzhong Li
- From the State Key Laboratory of Organ Failure Research, Department of Cardiology (Y. Lu, J.W., R.H., G.C., L.Z., S.S., C.Z., X.L., S.C., Y. Liao, J.B.) and Department of Oncology (W.L.), Nanfang Hospital, Southern Medical University, Guangzhou, China; and Department of Cardiology, the 458th Hospital of the Chinese People’s Liberation Army, Guangzhou, China (R.H.)
| | - Shiping Cao
- From the State Key Laboratory of Organ Failure Research, Department of Cardiology (Y. Lu, J.W., R.H., G.C., L.Z., S.S., C.Z., X.L., S.C., Y. Liao, J.B.) and Department of Oncology (W.L.), Nanfang Hospital, Southern Medical University, Guangzhou, China; and Department of Cardiology, the 458th Hospital of the Chinese People’s Liberation Army, Guangzhou, China (R.H.)
| | - Wangjun Liao
- From the State Key Laboratory of Organ Failure Research, Department of Cardiology (Y. Lu, J.W., R.H., G.C., L.Z., S.S., C.Z., X.L., S.C., Y. Liao, J.B.) and Department of Oncology (W.L.), Nanfang Hospital, Southern Medical University, Guangzhou, China; and Department of Cardiology, the 458th Hospital of the Chinese People’s Liberation Army, Guangzhou, China (R.H.)
| | - Yulin Liao
- From the State Key Laboratory of Organ Failure Research, Department of Cardiology (Y. Lu, J.W., R.H., G.C., L.Z., S.S., C.Z., X.L., S.C., Y. Liao, J.B.) and Department of Oncology (W.L.), Nanfang Hospital, Southern Medical University, Guangzhou, China; and Department of Cardiology, the 458th Hospital of the Chinese People’s Liberation Army, Guangzhou, China (R.H.)
| | - Jianping Bin
- From the State Key Laboratory of Organ Failure Research, Department of Cardiology (Y. Lu, J.W., R.H., G.C., L.Z., S.S., C.Z., X.L., S.C., Y. Liao, J.B.) and Department of Oncology (W.L.), Nanfang Hospital, Southern Medical University, Guangzhou, China; and Department of Cardiology, the 458th Hospital of the Chinese People’s Liberation Army, Guangzhou, China (R.H.)
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A Stroke Registry Data on the Use of Intravenous Recombinant Tissue Plasminogen Activator in Stroke of Unknown Time of Onset. J Stroke Cerebrovasc Dis 2016; 25:1843-50. [PMID: 27132489 DOI: 10.1016/j.jstrokecerebrovasdis.2016.03.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 03/19/2016] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Stroke of unknown time of onset (SUTO) constitutes one fifth of all ischemic stroke admissions, and routine use of intravenous recombinant tissue plasminogen activator (IV rtPA) is recommended only in patients with a symptom onset time of less than 4.5 hours. There are limited data on clinical outcome in patients with SUTO versus patients with symptoms onset less than 4.5 hours from onset time. We hypothesized that efficacy and safety outcomes of IV rtPA therapy in selected SUTO patients are comparable to those with known onset time. METHODS We compared 90 days' modified Rankin Scale (mRS), rates of symptomatic intracerebral hemorrhage (sICH), in-hospital mortality, and death due to sICH between 3 groups treated with IV rtPA: SUTO, 3 hours or less, and 3.0-4.5 hours from prospective patient admissions between April 1, 2012, and July 31, 2013. RESULTS There were 65 participants in the SUTO group, 186 in the 3 hours or less group, and 51 in the 3.0-4.5 hours group. In-hospital mortality rates were 14.5%, 13.5%, and 11.8%, respectively. sICH risks were 1.5%, 1.6%, and 5.8%, and death rates due to sICH were 0%, 1.1%, and 1.9%, respectively. Ninety days' odds of excellent clinical outcome (mRS score 0-1) were not different between the SUTO group (odds ratio [OR] 1.14, 95% confidence interval [CI]: .63-2.10), the 3 hours or less group (OR .87, 95% CI: .48-1.60), and the 3.0-4.5 hours group (OR .79, 95% CI: .48-1.60) (P = .82). CONCLUSION Thrombolytic therapy outcome in SUTO is not different from in-license use in our patient population. There is an urgent need to include this patient group in ongoing randomized multicenter trials.
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Malhotra K, Liebeskind DS. Wake-up stroke: Dawn of a new era. Brain Circ 2016; 2:72-79. [PMID: 30276276 PMCID: PMC6126251 DOI: 10.4103/2394-8108.186266] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/08/2016] [Accepted: 06/12/2016] [Indexed: 12/13/2022] Open
Abstract
Wake-up stroke or stroke with unclear onset of symptoms is known to occur in one-fourth of ischemic stroke patients. These patients are not considered for thrombolytic therapy based on time designation of their symptom onset as per the current guidelines. Observational studies have investigated the pathophysiology and suggested actual onset of symptoms to be approximate to the awakening time for these patients. Use of advanced imaging modalities in these patients tends to identify favorable patient profiles for thrombolysis. Results of the ongoing trials will likely beckon a seminal juncture in stroke therapy and deliver critical modifications in the current treatment guidelines for thrombolysis in this substantial, yet neglected, group of stroke patients. In this article, we have reviewed the predisposing factors, preferred imaging modalities and various ongoing thrombolytic and endovascular trials to date for patients with unclear time of symptom onset or who wake up with stroke symptoms.
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12
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Fabbian F, Manfredini R, De Giorgi A, Gallerani M, Cavazza M, Grifoni S, Fabbri A, Cervellin G, Ferrari AM, Imberti D. "Timing" of arrival and in-hospital mortality in a cohort of patients under anticoagulant therapy presenting to the emergency departments with cerebral hemorrhage: A multicenter chronobiological study in Italy. Chronobiol Int 2016; 33:245-56. [PMID: 26852790 DOI: 10.3109/07420528.2015.1133636] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Therapy with oral anticoagulants (OACs) is a risk factor for cerebral hemorrhage (CH). Although different studies have been undertaken to investigate the timing of the onset of major cardiovascular events, no data exist on temporal patterns of the onset of CH in subjects treated with OACs. The aim of this study is to evaluate the timing of CH in patients treated with OACs. All patients who developed CH under OACs therapy and admitted to 28 Italian Emergency Departments (EDs) between September 2011 and July 2013 were enrolled. Age, sex, time and location of the hemorrhagic lesion, type of the bleeding events (idiopathic or post-traumatic), anticoagulant therapy (warfarin or new oral anticoagulants - NOAs) and time of ED admission (i.e., hour, day, month and season) were recorded. Five hundred and seventeen patients (63.2% male aged 80 ± 7.9 yrs) with CH were involved. Warfarin was taken by 494 patients (95.6%), and NOAs by 23 (4.4%). In-hospital mortality (IHM) was recorded in 208 cases (40.2%). Cosinor analysis showed a peak of CH arrival between 12:00 and 14:00 h both in the whole population (PR 73.9%, p = 0.002) and the male subgroup (PR 65.2%, p = 0.009), whereas females showed an anticipated morning peak between 08:00 and 10:00 h (PR 65.7%, p = 0.008). A further analysis between idiopathic and post-traumatic CH confirmed the presence of a 24 h pattern with a peak between 12:00 and 14:00 h (PR 58.5%, p = 0.019) and between 08:00 and 10:00 h (PR80.1%, p < 0.001) for idiopathic events and post-traumatic hemorrhages, respectively. Moreover, a seasonal winter peak was identified for idiopathic forms (PR 74%, p = 0.035), and a summer peak for post-traumatic forms (PR 77%, p = 0.025). The present study suggests the presence of a temporal pattern of ED arrivals in CH patients treated with OACs.
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Affiliation(s)
- Fabio Fabbian
- a School of Medicine , University of Ferrara , Ferrara , Italy
| | | | | | - Massimo Gallerani
- b Department of Internal Medicine , University Hospital of Ferrara , Ferrara , Italy
| | - Mario Cavazza
- c Department of Emergency Medicine, General Surgery and Transplants , S. Orsola-Malpighi Hospital , Bologna , Italy
| | - Stefano Grifoni
- d Department of Emergency Medicine , University Hospital Careggi , Firenze , Italy
| | - Andrea Fabbri
- e Department of Emergency Medicine , Hospital of Forlì , Forlì , Italy
| | - Gianfranco Cervellin
- f Department of Emergency Medicine , University Hospital of Parma , Parma , Italy
| | - Anna Maria Ferrari
- g Department of Emergency Medicine , Hospital of Reggio Emilia , Reggio Emilia , Italy
| | - Davide Imberti
- h Internal Medicine , Hospital Guglielmo da Saliceto , Piacenza , Italy
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13
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Adams HP, Davis PH. Antithrombotic Therapy for Treatment of Acute Ischemic Stroke. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00052-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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14
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Morelli N, Rota E, Immovilli P, Cosottini M, Giorgi-Pierfranceschi M, Magnacavallo A, Michieletti E, Morelli J, Guidetti D. Computed tomography perfusion-based thrombolysis in wake-up stroke. Intern Emerg Med 2015; 10:977-84. [PMID: 26370239 DOI: 10.1007/s11739-015-1299-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 08/04/2015] [Indexed: 11/28/2022]
Abstract
Wake-up stroke (WUS) patients are typically excluded from reperfusion treatment, as the time of symptoms onset is unknown. The purpose of this study is to evaluate the clinical outcome and safety of intravenous thrombolysis with rt-PA in patients with WUS eligible for therapy using computed tomography perfusion criteria (CTP), compared to patients treated with rt-PA within 4.5 h of symptoms onset (non-WUS). This is an experimental, open-label trial, controlled against the best therapy currently in use. Primary endpoints were functional independence after 3 months [modified Rankin scale (mRS) ≤ 1] for clinical outcome and symptomatic intracerebral hemorrhage (SICH) for safety. Secondary endpoints were no or only mild disability after 3 months (mRS ≤ 2) for clinical outcome, total intracerebral hemorrhage (TICH) and contrast-induced nephropathy (CIN) for safety. 170 patients were treated, 143 non-WUS patients and 27 patients with WUS. Strokes of cardioembolic origin were most common in WUS patients (p < 0.001). Primary endpoints: mRS ≤ 1 was found in 35.8 % (non-WUS: 36.4% vs. WUS 33.3%; p = 0.62) and SICH was observed in 3.4 % of non-WUS patients and in WUS patients (p = 0.32). Secondary endpoints: mRS ≤ 2 was observed in 66.4 % of patients (non-WUS: 67.1% vs. WUS 62.9%; p = 0.67), TICH in 13.5 % of patients (13.9 % non-WUS vs. 11.1 % WUS; p = 0.69). CIN was documented in 3.7 % of WUS patients. rt-PA treatment carried out in WUS patients selected on the basis of CTP data demonstrate comparable clinical outcome and safety with respect to non-WUS patients. The study supports the hypothesis that a selected group of WUS patients may be suitable for thrombolysis.
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Affiliation(s)
- Nicola Morelli
- Neurology Unit, Guglielmo da Saliceto Hospital, Via Taverna 49, 29121, Piacenza, Italy.
- Radiology Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy.
| | - Eugenia Rota
- Neurology Unit, Guglielmo da Saliceto Hospital, Via Taverna 49, 29121, Piacenza, Italy
| | - Paolo Immovilli
- Neurology Unit, Guglielmo da Saliceto Hospital, Via Taverna 49, 29121, Piacenza, Italy
| | - Mirco Cosottini
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | | | | | - John Morelli
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Donata Guidetti
- Neurology Unit, Guglielmo da Saliceto Hospital, Via Taverna 49, 29121, Piacenza, Italy
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Mourand I, Milhaud D, Arquizan C, Lobotesis K, Schaub R, Machi P, Ayrignac X, Eker OF, Bonafé A, Costalat V. Favorable Bridging Therapy Based on DWI-FLAIR Mismatch in Patients with Unclear-Onset Stroke. AJNR Am J Neuroradiol 2015; 37:88-93. [PMID: 26542231 DOI: 10.3174/ajnr.a4574] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 06/02/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Standard selection criteria for revascularization therapy usually exclude patients with unclear-onset stroke. Our aim was to evaluate the efficacy and safety of revascularization therapy in patients with unclear-onset stroke in the anterior circulation and to identify the predictive factors for favorable clinical outcome. MATERIALS AND METHODS We retrospectively analyzed 41 consecutive patients presenting with acute stroke with unknown time of onset treated by intravenous thrombolysis and/or mechanical thrombectomy. Only patients without well-developed fluid-attenuated inversion recovery changes of acute diffusion lesions on MR imaging were enrolled. Twenty-one patients were treated by intravenous thrombolysis; 19 received, simultaneously, intravenous thrombolysis and mechanical thrombectomy (as a bridging therapy); and 1 patient, endovascular therapy alone. Clinical outcome was evaluated at 90 days by using the mRS. Mortality and symptomatic intracranial hemorrhage were also reported. RESULTS Median patient age was 72 years (range, 17-89 years). Mean initial NIHSS score was 14.5 ± 5.7. Successful recanalization (TICI 2b-3) was assessed in 61% of patients presenting with an arterial occlusion, symptomatic intracranial hemorrhage occurred in 2 patients (4.9%), and 3 (7.3%) patients died. After 90 days, favorable outcome (mRS 0-2) was observed in 25 (61%) patients. Following multivariate analysis, initial NIHSS score (OR, 1.43; 95% CI, 1.13-1.82; P = .003) and bridging therapy (OR, 37.92; 95% CI, 2.43-591.35; P = .009) were independently associated with a favorable outcome at 3 months. CONCLUSIONS The study demonstrates the safety and good clinical outcome of acute recanalization therapy in patients with acute stroke in the anterior circulation and an unknown time of onset and a DWI/FLAIR mismatch on imaging. Moreover, bridging therapy versus intravenous thrombolysis alone was independently associated with favorable outcome at 3 months.
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Affiliation(s)
- I Mourand
- From Departments of Neurology (I.M., D.M., C.A., X.A.)
| | - D Milhaud
- From Departments of Neurology (I.M., D.M., C.A., X.A.)
| | - C Arquizan
- From Departments of Neurology (I.M., D.M., C.A., X.A.)
| | - K Lobotesis
- Neuroradiology (K.L., P.M., O.F.E., A.B., V.C.)
| | - R Schaub
- Medical Information (R.S.), University Hospital Center of Montpellier, Gui de Chauliac Hospital, Montpellier, France
| | - P Machi
- Neuroradiology (K.L., P.M., O.F.E., A.B., V.C.)
| | - X Ayrignac
- From Departments of Neurology (I.M., D.M., C.A., X.A.)
| | - O F Eker
- Neuroradiology (K.L., P.M., O.F.E., A.B., V.C.)
| | - A Bonafé
- Neuroradiology (K.L., P.M., O.F.E., A.B., V.C.)
| | - V Costalat
- Neuroradiology (K.L., P.M., O.F.E., A.B., V.C.)
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16
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Coagulation factor XIIIa is inactivated by plasmin. Blood 2015; 126:2329-37. [PMID: 26359437 DOI: 10.1182/blood-2015-07-650713] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 08/28/2015] [Indexed: 11/20/2022] Open
Abstract
Coagulation factor XIIIa (FXIIIa) is a transglutaminase that covalently cross-links fibrin and other proteins to fibrin to stabilize blood clots and reduce blood loss. A clear mechanism to describe the physiological inactivation of FXIIIa has been elusive. Here, we show that plasmin can cleave FXIIIa in purified systems and in blood. Whereas zymogen FXIII was not readily cleaved by plasmin, FXIIIa was rapidly cleaved and inactivated by plasmin in solution (catalytic efficiency = 8.3 × 10(3) M(-1)s(-1)). The primary cleavage site identified by mass spectrometry was between K468 and Q469. Both plasma- and platelet-derived FXIIIa were susceptible to plasmin-mediated degradation. Inactivation of FXIIIa occurred during clot lysis and was enhanced both in plasma deficient in fibrinogen and in plasma treated with therapeutic levels of tissue plasminogen activator. These results indicate that FXIIIa activity can be modulated by fibrinolytic enzymes, and suggest that changes in fibrinolytic activity may influence cross-linking of blood proteins.
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17
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Abstract
Wake-up stroke, defined as the situation where a patient awakens with stroke symptoms that were not present prior to falling asleep, represents roughly 1 in 5 acute ischemic strokes and remains a therapeutic dilemma. Patients with wake-up stroke were excluded from most ischemic stroke treatment trials and are often not eligible for acute reperfusion therapy in clinical practice, leading to poor outcomes. Studies of neuroimaging with standard noncontrast computed tomography (CT), magnetic resonance imaging (MRI), and multimodal perfusion-based CT and MRI suggest wake-up stroke may occur shortly before awakening and may assist in selecting patients for acute reperfusion therapies. Pilot studies of wake-up stroke treatment based on these neuroimaging features are promising but have limited generalizability. Ongoing randomized treatment trials using neuroimaging-based patient selection may identify a subset of patients with wake-up stroke that can safely benefit from acute reperfusion therapies.
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Affiliation(s)
- Mark N Rubin
- Department of Neurology, Divisions of Hospital & Vascular Neurology, Mayo Clinic, Scottsdale, AZ, USA
| | - Kevin M Barrett
- Department of Neurology, Division of Vascular Neurology, Mayo Clinic, Jacksonville, FL, USA
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18
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Adams HP. IV thrombolysis for treatment of patients with stroke upon awakening: Yes? No? Neurol Clin Pract 2015; 5:296-301. [PMID: 26336630 DOI: 10.1212/cpj.0000000000000152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Current guidelines recommend IV administration of recombinant tissue plasminogen activator (rtPA) to carefully selected patients who can be treated within 4.5 hours of ischemic stroke onset. Patients whose neurologic symptoms are discovered upon awakening (wake-up stroke) generally are not given rtPA because of the uncertainty about the time of stroke onset. This group of patients may be relatively large. Preliminary reports suggest that patients with wake-up stroke who can be treated within 4.5 hours of discovery may respond similarly to patients with an established time of stroke onset. Clinical trials, which are selecting patients to treat primarily based on imaging surrogates, are under way. Pending the results of these trials, data about the utility of clinical or imaging findings that would identify those patients who could be treated and information about the safety and efficacy of IV rtPA in this situation are not available.
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Affiliation(s)
- Harold P Adams
- Department of Neurology, Division of Cerebrovascular Diseases, Carver College of Medicine and UIHC Stroke Center, University of Iowa, Iowa City
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19
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Kang J, Kim N, Park TH, Bang OY, Lee JS, Lee J, Han MK, Park SH, Gorelick PB, Bae HJ. Early statin use in ischemic stroke patients treated with recanalization therapy: retrospective observational study. BMC Neurol 2015. [PMID: 26224069 PMCID: PMC4520147 DOI: 10.1186/s12883-015-0367-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We aimed to determine whether early statin use following recanalization therapy improves the functional outcome of ischemic stroke. METHODS Using a prospective stroke registry database, we identified a consecutive 337 patients within 6 h of onset who had symptomatic stenosis or occlusion of major cerebral arteries and received recanalization therapy. Based on commencement of statin therapy, patients were categorized into administration on the first (D1, 13.4%), second (D2, 20.8%) and third day or later (D ≥ 3, 15.4%) after recanalization therapy, and no use (NU, 50.4%). The primary efficacy outcome was a 3-month modified Rankin Scale score of 0-1, and the secondary outcomes were neurologic improvement, neurologic deterioration and symptomatic hemorrhagic transformation during hospitalization. RESULTS Earlier use of statin was associated with a better primary outcome in a dose-response relationship (P for trend = 0.01) independent of premorbid statin use, stroke history, atrial fibrillation, stroke subtype, calendar year, and methods of recanalization therapy. The odds of a better primary outcome increased in D1 compared to NU (adjusted odds ratio, 2.96; 95% confidence interval, 1.19-7.37). Earlier statin use was significantly associated with less neurologic deterioration and symptomatic hemorrhagic transformation in bivariate analyses but not in multivariable analyses. Interaction analysis revealed that the effect of early statin use was not altered by stroke subtype and recanalization modality (P for interaction = 0.97 and 0.26, respectively). CONCLUSION Early statin use after recanalization therapy in ischemic stroke may improve the likelihood of a better functional outcome without increasing the risk of intracranial hemorrhage.
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Affiliation(s)
- Jihoon Kang
- Department of Neurology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea.
| | - Nayoung Kim
- Department of Neurology, Cerebrovascular center, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Korea.
| | - Tae Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea.
| | - Oh Young Bang
- Department of Neurology, Stroke and Cerebrovascular center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea.
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea.
| | - Moon-Ku Han
- Department of Neurology, Cerebrovascular center, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Korea.
| | - Seong-Ho Park
- Department of Neurology, Cerebrovascular center, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Korea.
| | - Philip B Gorelick
- Department of Translational Science and Molecular Medicine, Michigan State University College of Human Medicine & Saint Mary's Health Care at Mercy Health, Grand Rapids, Michigan, USA.
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular center, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Korea.
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20
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Ganti L. Do Glycoprotein IIb/IIIa Inhibitors Improve Outcomes in Acute Ischemic Stroke? Ann Emerg Med 2015; 66:65-6. [DOI: 10.1016/j.annemergmed.2015.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Indexed: 10/23/2022]
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21
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Abstract
The current standard care for acute coronary syndromes is dual antiplatelet therapy combining the COX1 inhibitor aspirin with a drug targeting the P2Y12 receptor, together with anticoagulation during and after early revascularization by percutaneous intervention. In very high-risk patients, glycoprotein (GP) IIb/IIIa antagonists may also be used. Secondary prevention of ischemic events requires dual antiplatelet therapy for several months followed by lifelong low-dose aspirin. The duration of treatment and the drugs to combine nevertheless remain matters of debate and the focus of ongoing research. Despite great progress, there is still room for improved efficacy and this could involve new targets for both antiplatelet drugs (like the thrombin receptor PAR1) and anticoagulants. However, improved efficacy is offset by an increased risk of bleeding. Stroke patients are still waiting for better treatment, their bleeding risk being particularly high. New targets including the collagen receptor, glycoprotein VI (GPVI), and the GPIb-von Willebrand factor axis, governing platelet interaction with the diseased vessel wall, should enable us to complete the armamentarium of antiplatelet drugs.
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Affiliation(s)
- C Gachet
- UMR_S949, INSERM, Strasbourg, France
- Etablissement Français du Sang-Alsace (EFS-Alsace), Strasbourg, France
- Université de Strasbourg, Strasbourg, France
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22
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Denny MC, Boehme AK, Dorsey AM, George AJ, Yeh AD, Albright KC, Martin-Schild S. Wake-up Strokes Are Similar to Known-Onset Morning Strokes in Severity and Outcome. ACTA ACUST UNITED AC 2014; 1. [PMID: 26835514 DOI: 10.15744/2454-4981.1.102] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Stroke symptoms noticed upon waking, wake-up stroke, account for up to a quarter of all acute ischemic strokes. Patients with wake-up stroke, however, are often excluded from thrombolytic therapy. METHODS Using our prospectively collected stroke registry, wake-up stroke and known-onset morning strokes were identified. Wakeup stroke was defined as a patient who was asleep >3 hours and first noted stroke symptoms upon awakening between 0100 and 1100. Known-onset morning stroke was defined as a patient who had symptom onset while awake during the same time interval. We compared wake-up stoke to known-onset morning stroke with respect to patient demographics, stroke severity, etiology and outcomes. RESULTS One-quarter of patients with acute ischemic strokes (391/1415) had documented time between 0100 and 1100 of symptom onset: 141 (36%) wake-up strokes and 250 (64%) known-onset morning strokes. No difference in baseline characteristics, stroke severity, stroke etiology, neurologic deterioration, discharge disposition or functional outcome was detected. Known-onset morning stroke patients were significantly more likely to get thrombolytic therapy and have higher risk of in-hospital mortality. Wake-up stroke patients tended to be older, have higher diastolic blood pressure and have longer length of hospital stay. DISCUSSION While patients with wake-up stroke were similar to patients with known-onset morning stroke in many respects, patients with known onset morning stroke were significantly more likely to get treated with thrombolytic therapy and have higher in-hospital mortality.
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Affiliation(s)
- M C Denny
- Department of Neurology, Medstar Georgetown University Hospital, Washington, DC; Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, LA
| | - A K Boehme
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham; Department of Neurology, School of Medicine, University of Alabama at Birmingham
| | - A M Dorsey
- Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, LA
| | - A J George
- Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, LA
| | - A D Yeh
- Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, LA
| | - K C Albright
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham; Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (COERE); Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities (CERED) Minority Health and Health Disparities Research Center (MHRC); Department of Neurology, School of Medicine, University of Alabama at Birmingham
| | - S Martin-Schild
- Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, LA
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23
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Wouters A, Lemmens R, Dupont P, Thijs V. Wake-up stroke and stroke of unknown onset: a critical review. Front Neurol 2014; 5:153. [PMID: 25161646 PMCID: PMC4129498 DOI: 10.3389/fneur.2014.00153] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 07/27/2014] [Indexed: 11/15/2022] Open
Abstract
Patients, who wake up with an ischemic stroke, account for a large number of the total stroke population, due to circadian morning predominance of stroke. Currently, this subset of patients is excluded from revascularization-therapy since no exact time of onset is known. A large group of these patients might be eligible for therapy. In this review, we assessed the current literature about the hypothesis that wake-up-strokes occur just prior on awakening and if this subgroup differs in characteristics compared to the overall stroke population. We looked at the safety and efficacy of thrombolysis and interventional techniques in the group of patients with unknown stroke-onset. We performed a meta-analysis of the diagnostic accuracy of the diffusion-FLAIR mismatch in identifying stroke within 3 and 4.5 h. The different imaging-selection criteria that can be used to treat these patients are discussed. Additional research on imaging findings associated with recent stroke and penumbral imaging will eventually lead to a shift from a rigid time-frame based therapy to a tissue-based individualized treatment approach.
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Affiliation(s)
- Anke Wouters
- KU Leuven Department of Neurosciences and Experimental Neurology, KU Leuven , Leuven , Belgium ; Department of Neurology, University Hospital Leuven , Leuven , Belgium ; Medical Imaging Research Center, UZ Leuven , Leuven , Belgium
| | - Robin Lemmens
- KU Leuven Department of Neurosciences and Experimental Neurology, KU Leuven , Leuven , Belgium ; Department of Neurology, University Hospital Leuven , Leuven , Belgium ; Leuven Research Institute for Neuroscience and Disease (LIND), KU Leuven , Leuven , Belgium ; Laboratory of Neurobiology, Vesalius Research Center , Leuven , Belgium
| | - Patrick Dupont
- Medical Imaging Research Center, UZ Leuven , Leuven , Belgium ; Laboratory for Epilepsy Research, KU Leuven , Leuven , Belgium ; Laboratory for Cognitive Neurology, KU Leuven , Leuven , Belgium
| | - Vincent Thijs
- KU Leuven Department of Neurosciences and Experimental Neurology, KU Leuven , Leuven , Belgium ; Department of Neurology, University Hospital Leuven , Leuven , Belgium ; Leuven Research Institute for Neuroscience and Disease (LIND), KU Leuven , Leuven , Belgium ; Laboratory of Neurobiology, Vesalius Research Center , Leuven , Belgium
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24
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Abstract
Acute ischemic stroke is the fourth leading cause of death and the leading cause of disability in the United States. Stroke is a medical emergency. The development of stroke systems of care has changed the way practitioners view and treat this devastating disease. Ample evidence has shown that patients presenting early and receiving intravenous thrombolytic therapy have the best chance for significant improvement in functional outcome, particularly if they are transported to specialized stroke centers. Early detection and management of medical and neurologic complications is key at preventing further brain damage in patients with acute ischemic stroke.
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Affiliation(s)
- Nelson J Maldonado
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA
| | - Syed O Kazmi
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA
| | - Jose Ignacio Suarez
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA.
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25
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Affiliation(s)
- Deborah Buck
- From the Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle, United Kingdom (D.B., L.C.S., C.I.P.); and Medical Sciences Division, University of Oxford, Oxford, United Kingdom (G.A.F.)
| | - Lisa C. Shaw
- From the Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle, United Kingdom (D.B., L.C.S., C.I.P.); and Medical Sciences Division, University of Oxford, Oxford, United Kingdom (G.A.F.)
| | - Christopher I. Price
- From the Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle, United Kingdom (D.B., L.C.S., C.I.P.); and Medical Sciences Division, University of Oxford, Oxford, United Kingdom (G.A.F.)
| | - Gary A. Ford
- From the Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle, United Kingdom (D.B., L.C.S., C.I.P.); and Medical Sciences Division, University of Oxford, Oxford, United Kingdom (G.A.F.)
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Ciccone A, Motto C, Abraha I, Cozzolino F, Santilli I. Glycoprotein IIb-IIIa inhibitors for acute ischaemic stroke. Cochrane Database Syst Rev 2014:CD005208. [PMID: 24609741 DOI: 10.1002/14651858.cd005208.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Glycoprotein (GP) IIb-IIIa inhibitors are antiplatelet agents that act by antagonising GP IIb-IIIa receptors on the platelet surface and block the final common pathway to platelet aggregation by preventing the binding of fibrinogen molecules that form bridges between adjacent platelets. Thus, GP IIb-IIIa inhibitors could favour endogenous thrombolysis by reducing thrombus growth and preventing thrombus re-formation through competitive inhibition with fibrinogen and, due to their mechanism of action, are likely to have a more profound antiplatelet effect with more rapid onset than conventional antiplatelet agents, such as aspirin or clopidogrel. Currently used in clinical practice for the treatment of individuals with acute coronary syndromes and during coronary angioplasty, GP IIb-IIIa inhibitors could also be useful for the treatment of people with acute ischaemic stroke. OBJECTIVES To assess the use of GP IIb-IIIa inhibitors in people with acute ischaemic stroke to evaluate whether such treatments (1) reduce the proportion of patients who die or remain dependent, and (2) are sufficiently safe for general use. We wished to examine the effects GP IIb-IIIa inhibitors alone or in combination with thrombolytic agents. SEARCH METHODS We searched the Cochrane Stroke Group trials register (last searched 10 June 2013), MEDLINE (1966 to June 2013), EMBASE (1980 to June 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 5, 2013), and major ongoing clinical trials registers (June 2013). We also searched reference lists and contacted trial authors and pharmaceutical companies. SELECTION CRITERIA We aimed to analyse unconfounded randomised controlled trials (RCTs) of GP IIb-IIIa inhibitors in the treatment of people with acute ischaemic stroke. Only individuals who started treatment within six hours of stroke onset were included. DATA COLLECTION AND ANALYSIS We independently selected trials for inclusion, assessed trial quality and extracted the data. MAIN RESULTS We included four trials involving 1365 participants. Three trials compared the intravenous GP IIb-IIIa inhibitor Abciximab with intravenous placebo (1215 participants) and one trial compared the intravenous GP IIb-IIIa inhibitor Tirofiban with intravenous aspirin (150 participants). Treatment with either of these GP IIb-IIIa inhibitors did not significantly reduce long-term death or dependency (odds ratio (OR) 0.97, 95% confidence interval (CI) 0.77 to 1.22, for the comparison between Abciximab and placebo; OR 1.00, 95% CI 0.52 to 1.92, for the comparison between Tirofiban and aspirin) and had no effect on deaths from all causes (OR 1.08, 95% CI 0.77 to 1.53, for the comparison between Abciximab and placebo; OR 1.00, 95% CI 0.35 to 2.82, for the comparison between Tirofiban and aspirin). Abciximab was associated with a significant increase in symptomatic intracranial haemorrhage (OR 4.6, 95% CI 2.01 to 10.54) and with a non-significant increase in major extracranial haemorrhage (OR 1.81, 95% CI 0.96 to 3.41), whereas the only small trial comparing Tirofiban with aspirin showed no increased risk of bleeding complications with Tirofiban (OR 0.32, 95% CI 0.03 to 3.19, for symptomatic intracranial haemorrhage; OR 3.04, 95% CI 0.12 to 75.83, for major extracranial haemorrhages). There was no significant inconsistency across the studies. AUTHORS' CONCLUSIONS The available trial evidence showed that, for individuals with acute ischaemic stroke, GP IIb-IIIa inhibitors are associated with a significant risk of intracranial haemorrhage with no evidence of any reduction in death or disability in survivors. These data do not support their routine use in clinical practice. The conclusion is driven by trials of Abciximab, which contributed 89% of the total number of study participants considered.
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Affiliation(s)
- Alfonso Ciccone
- Department of Neurology and Stroke Unit, "Carlo Poma" Hospital, Strada Lago Paiolo 10, Mantua, Italy, 46100
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27
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Cortijo E, García-Bermejo P, Calleja AI, Pérez-Fernández S, Gómez R, del Monte JM, Reyes J, Arenillas JF. Intravenous thrombolysis in ischemic stroke with unknown onset using CT perfusion. Acta Neurol Scand 2014; 129:178-83. [PMID: 23848212 DOI: 10.1111/ane.12160] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acute ischemic stroke patients with unclear onset time presenting >4.5 h from last-seen-normal (LSN) time are considered late patients and excluded from i.v. thrombolysis. We aimed to evaluate whether this subgroup of patients is different from patients presenting >4.5 h from a witnessed onset, in terms of eligibility and response to computed tomography perfusion (CTP)-guided i.v. thrombolysis. METHODS We prospectively studied consecutive acute non-lacunar middle cerebral artery (MCA) ischemic stroke patients presenting >4.5 h from LSN. All patients underwent multimodal CT and were considered eligible for i.v. thrombolysis according to CTP criteria. Two patient groups were established based on the knowledge of the stroke onset time. We compared the proportion of candidates suitable for intravenous thrombolysis between both groups, and their outcome after thrombolytic therapy. RESULTS Among 147 MCA ischemic stroke patients presenting >4.5 h from LSN, stroke onset was witnessed in 74 and unknown in 73. Thirty-seven (50%) patients in the first group and 32 (44%) in the second met CTP criteria for thrombolysis (P = 0.7). Baseline variables were comparable between both groups with the exception of age, which was higher in the unclear onset group. The rates of early neurological improvement (54.1% vs 46.9%), 2-h MCA recanalization (43.5% vs 37%), symptomatic hemorrhagic transformation (3% vs 0%) and good 3-month functional outcome (62.2% vs 56.3%) did not differ significantly between both groups. CONCLUSION Delayed stroke patients with unknown onset time were no different than patients >4.5 h regarding eligibility and response to CTP-based i.v. thrombolysis.
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Affiliation(s)
- E. Cortijo
- Stroke Unit; Department of Neurology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| | - P. García-Bermejo
- Stroke Unit; Department of Neurology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| | - A. I. Calleja
- Stroke Unit; Department of Neurology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| | - S. Pérez-Fernández
- Section of Neuroradiology; Department of Radiology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| | - R. Gómez
- Section of Neuroradiology; Department of Radiology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| | - J. M. del Monte
- Section of Neuroradiology; Department of Radiology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| | - J. Reyes
- Stroke Unit; Department of Neurology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| | - J. F. Arenillas
- Stroke Unit; Department of Neurology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
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Millán M, Aleu A, Almendrote M, Serena J, Castaño C, Roquer J, Pérez de la Ossa N, Gomis M, Dorado L, López-Cancio E, García-Bermejo P, Hernández-Pérez M, Dávalos A. Safety and effectiveness of endovascular treatment of stroke with unknown time of onset. Cerebrovasc Dis 2014; 37:134-40. [PMID: 24481476 DOI: 10.1159/000357419] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 11/19/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Currently, treatment options for patients with strokes with unknown time of onset (UKO) remain limited. With the advance of neuroimaging and endovascular treatment (EVT), selected patients might have a chance of a therapeutic option. We sought to compare clinical outcome after EVT in patients with known time of stroke onset (KO) and in those with UKO. METHODS We prospectively registered consecutive patients with acute large artery occlusion of the anterior territory who underwent EVT. Multimodal MR or Alberta Stroke Program early CT score (ASPECTS) and transcranial color-coded Duplex sonography were used to select patients for EVT. Recanalization, periprocedural complications, intracranial hemorrhage (ICH) and outcome were recorded. Symptomatic ICH (sICH) was defined as a worsening of ≥4 points in the National Institutes of Health Stroke Scale (NIHSS) score within 36 h in any bleeding. Favorable outcome was defined as a modified Rankin score ≤2 at 3 months. RESULTS A total of 141 patients were studied, 109 with KO and 32 with UKO. Mean age was 66.5 versus 64.7 years (p = 0.005) and median baseline NIHSS was 18 versus 17 (p = 0.095), respectively. Prior IV tPA was more frequently administered to KO patients (62.4 vs. 9.4%, p < 0.001), whereas patient selection using multimodal MR was more frequent in patients with UKO (78.1 vs. 45.4%, p < 0.001). Median time from stroke onset or from the last time the patient was seen well to groin puncture and to recanalization was significantly longer in patients with UKO, but no differences were found in the duration of the procedure. For KO/UKO patients recanalization was seen in 77.1 vs. 65.7% (p = 0.084), sICH occurred in 10 versus 0% (p = 0.061) and favorable outcome at 3 months was achieved in 41.3 versus 50% (p = 0.382), respectively. CONCLUSIONS Clinical outcomes in this series of EVT in ischemic stroke patients due to large anterior arterial occlusion with salvageable brain are similar for patients treated with KO and UKO. These data support a randomized study of EVT in extended or uncertain time windows..
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Affiliation(s)
- M Millán
- Department of Neurosciences, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
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Block HS, Biller J. Commonly asked questions: thrombolytic therapy in the management of acute stroke. Expert Rev Neurother 2014; 13:157-65. [DOI: 10.1586/ern.12.163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Maas AIR, Murray GD, Roozenbeek B, Lingsma HF, Butcher I, McHugh GS, Weir J, Lu J, Steyerberg EW. Advancing care for traumatic brain injury: findings from the IMPACT studies and perspectives on future research. Lancet Neurol 2013; 12:1200-10. [PMID: 24139680 DOI: 10.1016/s1474-4422(13)70234-5] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Research in traumatic brain injury (TBI) is challenging for several reasons; in particular, the heterogeneity between patients regarding causes, pathophysiology, treatment, and outcome. Advances in basic science have failed to translate into successful clinical treatments, and the evidence underpinning guideline recommendations is weak. Because clinical research has been hampered by non-standardised data collection, restricted multidisciplinary collaboration, and the lack of sensitivity of classification and efficacy analyses, multidisciplinary collaborations are now being fostered. Approaches to deal with heterogeneity have been developed by the IMPACT study group. These approaches can increase statistical power in clinical trials by up to 50% and are also relevant to other heterogeneous neurological diseases, such as stroke and subarachnoid haemorrhage. Rather than trying to limit heterogeneity, we might also be able to exploit it by analysing differences in treatment and outcome between countries and centres in comparative effectiveness research. This approach has great potential to advance care in patients with TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.
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Aoki J, Kimura K, Shibazaki K, Sakamoto Y. Negative fluid-attenuated inversion recovery-based intravenous thrombolysis using recombinant tissue plasminogen activator in acute stroke patients with unknown onset time. Cerebrovasc Dis Extra 2013; 3:35-45. [PMID: 24052793 PMCID: PMC3776711 DOI: 10.1159/000348552] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Approximately 25% of acute stroke patients were excluded from intravenous thrombolysis using recombinant tissue plasminogen activator (IV-tPA) because of unknown onset time. Recent studies have shown that patients with unknown onset time would be able to receive IV-tPA when showing no ischemia on fluid-attenuated inversion recovery (negative FLAIR). The present study evaluated the safety and feasibility of IV-tPA in patients with unknown onset time and negative FLAIR compared to those with standard IV-tPA. METHODS Stroke patients with unknown onset time were prospectively enrolled. Only patients with an occlusion of the internal carotid artery (ICA) and/or middle cerebral artery (M1 and M2) with a Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score (DWI-ASPECTS) ≥5 were analyzed. IV-tPA was performed within 3 h from the 'first found abnormal time' if the patient showed negative FLAIR. Standard IV-tPA patients were extracted from our registry as controls after having been matched by age and occluded artery to the negative FLAIR (N-F) group. RESULTS Twenty patients in the N-F group and 60 in the control group were included. National Institutes of Health Stroke Scale (NIHSS) scores [median 18 (interquartile range 13-20) vs. 17 (12-20), p = 0.609] and DWI-ASPECTS [9 (7-9) vs. 8 (5-9), p = 0.213] were similar between the 2 groups. ICA occlusion was seen in 35%, M1 in 50%, and M2 in 15% in both groups. None of the N-F group and 1 (2%) of the control group experienced symptomatic intracerebral hemorrhage (p = 1.000). Recanalization within 1 h after IV-tPA was achieved in 6 (30%) patients in the N-F group and 24 (40%) in the control group (p = 0.595). Recanalization at 24 h after IV-tPA was seen in 13 (65%) patients in the N-F group and 43 (72%) in the control group (p = 0.584). At 7 days, 8 (40%) in the N-F group and 28 (47%) in the control group had a dramatic recovery (defined as a ≥10-point reduction in the total NIHSS score or a score of 0 or 1) (p = 0.796). At 3 months, a favorable outcome (modified Rankin scale score, 0-2) was seen in 47% in the N-F group and 33% in the control group (p = 0.365). CONCLUSION IV-tPA in negative FLAIR patients with unknown onset time appears safe and feasible.
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Affiliation(s)
- Junya Aoki
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
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Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJB, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870-947. [PMID: 23370205 DOI: 10.1161/str.0b013e318284056a] [Citation(s) in RCA: 3215] [Impact Index Per Article: 292.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. METHODS Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. RESULTS The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. CONCLUSIONS Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.
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Jung S, Gralla J, Fischer U, Mono ML, Weck A, Lüdi R, Heldner MR, Findling O, El-Koussy M, Brekenfeld C, Schroth G, Mattle HP, Arnold M. Safety of endovascular treatment beyond the 6-h time window in 205 patients. Eur J Neurol 2013; 20:865-71. [DOI: 10.1111/ene.12069] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 11/01/2012] [Indexed: 11/28/2022]
Affiliation(s)
| | - J. Gralla
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Berne; Berne; Switzerland
| | - U. Fischer
- Department of Neurology; Inselspital; University Hospital Bern and University of Berne; Berne; Switzerland
| | - M.-L. Mono
- Department of Neurology; Inselspital; University Hospital Bern and University of Berne; Berne; Switzerland
| | - A. Weck
- Department of Neurology; Inselspital; University Hospital Bern and University of Berne; Berne; Switzerland
| | - R. Lüdi
- Department of Neurology; Inselspital; University Hospital Bern and University of Berne; Berne; Switzerland
| | - M. R. Heldner
- Department of Neurology; Inselspital; University Hospital Bern and University of Berne; Berne; Switzerland
| | - O. Findling
- Department of Neurology; Inselspital; University Hospital Bern and University of Berne; Berne; Switzerland
| | - M. El-Koussy
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Berne; Berne; Switzerland
| | - C. Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Berne; Berne; Switzerland
| | - G. Schroth
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Berne; Berne; Switzerland
| | - H. P. Mattle
- Department of Neurology; Inselspital; University Hospital Bern and University of Berne; Berne; Switzerland
| | - M. Arnold
- Department of Neurology; Inselspital; University Hospital Bern and University of Berne; Berne; Switzerland
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Kang DW, Sohn SI, Hong KS, Yu KH, Hwang YH, Han MK, Lee J, Park JM, Cho AH, Kim HJ, Kim DE, Cho YJ, Koo J, Yun SC, Kwon SU, Bae HJ, Kim JS. Reperfusion therapy in unclear-onset stroke based on MRI evaluation (RESTORE): a prospective multicenter study. Stroke 2012; 43:3278-83. [PMID: 23093613 DOI: 10.1161/strokeaha.112.675926] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Unclear-onset strokes are generally excluded from time-based thrombolytic therapy. We examined the safety and feasibility of magnetic resonance imaging-based reperfusion therapy in unclear-onset stroke. METHODS This prospective, multicenter, single-arm study screened consecutive unclear-onset stroke patients within 6 hours of symptom detection. Patients with perfusion-diffusion mismatch>20% and negative or subtle fluid-attenuated inversion recovery changes were treated with intravenous tissue plasminogen activator, intra-arterial therapy, or a combination. The safety outcome was symptomatic intracranial hemorrhage within 48 hours after treatment. The primary efficacy outcome was a 3-month modified Rankin Scale score of 0 to 2. Controls were untreated unclear-onset stroke patients prospectively captured in stroke registries. RESULTS Of 430 unclear-onset stroke patients, 83 (19.3%) received reperfusion therapy (mean age, 67.5±10.4 years; males, 66.3%; median baseline National Institutes of Health Stroke Scale, 14). Symptomatic intracranial hemorrhage with any neurological decline developed in 5 patients (6.0%). Symptomatic intracranial hemorrhage with National Institutes of Health Stroke Scale worsening ≥4 developed in 3 patients (3.6%). Thirty-seven patients (44.6%) achieved modified Rankin Scale score of 0 to 2, and 24 (28.9%) had modified Rankin Scale score of 0 to 1. Female, baseline National Institutes of Health Stroke Scale score, no immediate or early recanalization, and more white blood cells were independent predictors of poor outcome. Compared with untreated controls, the treated group was significantly associated with good outcomes of modified Rankin Scale score of 0 to 2 after adjusting for age, sex, and baseline National Institutes of Health Stroke Scale in logistic regression analysis (odds ratio, 2.25; 95% CI, 1.14-4.49). CONCLUSIONS In unclear-onset stroke patients, magnetic resonance imaging-based reperfusion therapy was feasible and safe. Randomized controlled trials are warranted to confirm the benefit of reperfusion therapy for unclear-onset stroke.
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Affiliation(s)
- Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, and Eulji General Hospital, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul 138-736, South Korea.
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Moradiya Y, Janjua N. Presentation and outcomes of "wake-up strokes" in a large randomized stroke trial: analysis of data from the International Stroke Trial. J Stroke Cerebrovasc Dis 2012; 22:e286-92. [PMID: 22939198 DOI: 10.1016/j.jstrokecerebrovasdis.2012.07.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 07/10/2012] [Accepted: 07/20/2012] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Recent studies comparing the outcomes of wake-up stroke (WUS) and stroke while awake (SWA) patients reveal better outcomes among SWA patients, attributable in part to their higher rates of thrombolysis. Patients with WUS are largely excluded from therapy. Earlier analyses, conducted before the approval of alteplase for acute stroke, show the true divergence of natural histories between these 2 groups. METHODS We analyzed 17,398 patients with ischemic stroke from the International Stroke Trial and compared both presentations and outcomes between the WUS and SWA groups. Severity was assessed by level of consciousness, Oxfordshire Community Stroke Project (OCSP) stroke classification, number of neurologic deficits, and predicted probability of dependency or death. Outcomes were assessed at day 14 and at 6 months. Outcome assessments were controlled for potential confounders. RESULTS WUS represented 29.6% of all ischemic strokes. More severe OSCP stroke type (total anterior circulation syndrome) was less common in WUS. Although more patients with WUS were alert at presentation with a lower predicted probability of dependency, the 14-day mortality rates and rates of poor outcome at 6 months were similar between the 2 groups. CONCLUSIONS WUS patients comprise one quarter to one third of ischemic stroke patients. Despite their more benign presentations, they deteriorate to outcome rates similar to SWA. Although they are typically excluded from time-dependent acute interventions, patients with WUS may benefit from acute intervention to prevent this worsening natural history.
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Affiliation(s)
- Yogesh Moradiya
- Department of Neurology, SUNY Downstate Medical Center, Brooklyn, New York.
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Hiraga A. Can we extend thrombolytic treatment for wake-up stroke? Neuroepidemiology 2012; 39:154-5. [PMID: 22922565 DOI: 10.1159/000341747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Akiyuki Hiraga
- Department of Neurology, Chiba Rosai Hospital, Chiba, Japan.
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Song SS, Latour LL, Ritter CH, Wu O, Tighiouart M, Hernandez DA, Ku KD, Luby M, Warach S. A pragmatic approach using magnetic resonance imaging to treat ischemic strokes of unknown onset time in a thrombolytic trial. Stroke 2012; 43:2331-5. [PMID: 22693129 DOI: 10.1161/strokeaha.111.630947] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Toward the goal of designing a clinical trial using imaging parameters to treat stroke patients with unknown onset time, we investigated the timing of changes on MRI in patients with well-defined stroke onset. METHODS Hypothesis-generating (n=85) and confirmatory (n=111) samples were scored by blinded readers for fluid-attenuated inversion recovery (FLAIR) hyperintensity in diffusion-positive regions. Reader-measured signal intensity ratio (SIR) of the lesion to contralateral tissue was compared with SIR measured by coregistration. RESULTS Lesion conspicuity increased with time on FLAIR (P=0.006). Qualitative assessment of FLAIR-negative vs FLAIR hyperintensity (k=0.7091; 95% CI, 0.61-0.81) showed good interrater agreement. Subtle hyperintensity was less reliably categorized (k=0.59; 95% CI, 0.47-0.71). Reader-measured SIR <1.15 can identify patients within the treatable time window of 4.5 hours (positive predictive value=0.90). The SIR was greater for right hemisphere lesions (P=0.04) for a given reported time from stroke symptom onset. CONCLUSIONS The SIR on FLAIR provides a quantitative tool to identify early ischemic strokes. In developing SIR thresholds, right hemisphere lesions may confound the accurate estimate of stroke onset time. Image coregistration for thrombolytic trial enrollment is not necessary. A SIR <1.15 on FLAIR yields a practical estimate of stroke onset within 4.5 hours.
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Affiliation(s)
- Shlee S Song
- Stroke Program, Department of Neurology, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians E-216, Los Angeles, CA, USA.
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Kang DW, Kwon JY, Kwon SU, Kim JS. Wake-up or unclear-onset strokes: are they waking up to the world of thrombolysis therapy? Int J Stroke 2012; 7:311-20. [PMID: 22510216 DOI: 10.1111/j.1747-4949.2012.00779.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Wake-up or unclear-onset strokes occur in up to one-fourth of patients with ischemic stroke. Although stroke severity and clinical outcomes appear to be poorer in wake-up strokes than nonwake-up strokes, many patients with wake-up strokes do not receive thrombolytic therapy because stroke onset time cannot be determined. Recent studies have suggested, however, that the actual onset time of wake-up stroke is close to the wake-up time. Furthermore, advanced imaging technologies may enable us to identify patients with favorable risk-benefit profiles for thrombolysis. Indeed, empirical thrombolytic treatments have suggested safety and feasibility of such therapy in these patients. Based on these promising results and the development of multimodal imaging methods, prospective thrombolysis trials using predefined imaging criteria are currently under way to test the safety and efficacy of thrombolysis in patients with wake-up or unclear-onset strokes. The establishment of optimal acute treatment strategies in this important yet so far neglected group of patients is eagerly awaited.
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Affiliation(s)
- Dong-Wha Kang
- Stroke Center and Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Roveri L, La Gioia S, Ghidinelli C, Anzalone N, De Filippis C, Comi G. Wake-up stroke within 3 hours of symptom awareness: imaging and clinical features compared to standard recombinant tissue plasminogen activator treated stroke. J Stroke Cerebrovasc Dis 2011; 22:703-8. [PMID: 22133742 DOI: 10.1016/j.jstrokecerebrovasdis.2011.10.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 10/06/2011] [Accepted: 10/15/2011] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Patients with wake-up stroke (WUS) are excluded from thrombolysis because of unknown time of symptom onset. Previous studies have reported similar stroke severity and early ischemic changes (EICs) in patients with WUS and stroke of known onset. These studies, however, included patients within a large timeframe to imaging or did not quantify EICs. The aim of our study was to quantify EICs of patients with WUS presenting within 3 hours of symptom recognition compared to standard 3-hours recombinant tissue plasminogen activator (rt-PA)-treated patients and assess the extent of ischemic lesion and functional independence at follow-up. METHODS Patients were selected from our prospectively collected stroke database. Baseline and follow-up computed tomographic scans were graded with Alberta Stroke Program Early Computed Tomography Score (ASPECTS). Clinical outcome measures were modified Rankin Scale score, mortality, and symptomatic intracerebral hemorrhage. RESULTS Demographic features, risk factors, stroke severity, and baseline ASPECTS were similar in both groups. WUS and rt-PA-treated patients had similar tissue outcome (median ASPECTS 7.0 vs 7.5; P = .202). Functional outcome was more favorable in rt-PA-treated patients (61.6% vs 43.1%; odds ratio [OR] 2.12; 95% confidence interval [CI] 1.05-4.28; P = .037). After adjusting for age, stroke severity, treatment, and EICs in less than one-third of middle cerebral artery territory, rt-PA and National Institutes of Health Stroke Scale scores remained the only significant predictors of outcome (OR 7.76; 95% CI 2.40-25.05; P = .001 and OR 0.74; 95% CI 0.67-0.82; P < .001, respectively). CONCLUSIONS Within 3 hours of symptom recognition, patients with WUS have EICs similar to rt-PA-treated patients. It is reasonable to expect that selected WUS patients might benefit from thrombolysis within 3 hours of symptom awareness.
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Affiliation(s)
- Luisa Roveri
- Department of Neurology, San Raffaele Scientific Institute, Milan, Italy.
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Vivien D, Gauberti M, Montagne A, Defer G, Touzé E. Impact of tissue plasminogen activator on the neurovascular unit: from clinical data to experimental evidence. J Cereb Blood Flow Metab 2011; 31:2119-34. [PMID: 21878948 PMCID: PMC3210341 DOI: 10.1038/jcbfm.2011.127] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
About 15 million strokes occur each year worldwide. As the number one cause of morbidity and acquired disability, stroke is a major drain on public health-care funding, due to long hospital stays followed by ongoing support in the community or nursing-home care. Although during the last 10 years we have witnessed a remarkable progress in the understanding of the pathophysiology of ischemic stroke, reperfusion induced by recombinant tissue-type plasminogen activator (tPA-Actilyse) remains the only approved acute treatment by the health authorities. The objective of the present review is to provide an overview of our present knowledge about the impact of tPA on the neurovascular unit during acute ischemic stroke.
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Affiliation(s)
- Denis Vivien
- Inserm UMR-S 919, Serine Proteases and Pathophysiology of the Neurovascular Unit, GIP Cyceron, Université de Caen Basse-Normandie, Caen Cedex, France.
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Michel P, Ntaios G, Reichhart M, Schindler C, Bogousslavsky J, Maeder P, Meuli R, Wintermark M. Perfusion-CT guided intravenous thrombolysis in patients with unknown-onset stroke: a randomized, double-blind, placebo-controlled, pilot feasibility trial. Neuroradiology 2011; 54:579-88. [PMID: 21808985 DOI: 10.1007/s00234-011-0944-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 07/25/2011] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Patients with unknown stroke onset are generally excluded from acute recanalisation treatments. We designed a pilot study to assess feasibility of a trial of perfusion computed tomography (PCT)-guided thrombolysis in patients with ischemic tissue at risk of infarction and unknown stroke onset. METHODS Patients with a supratentorial stroke of unknown onset in the middle cerebral artery territory and significant volume of at-risk tissue on PCT were randomized to intravenous thrombolysis with alteplase (0.9 mg/kg) or placebo. Feasibility endpoints were randomization and blinded treatment of patients within 2 h after hospital arrival, and the correct application (estimation) of the perfusion imaging criteria. RESULTS At baseline, there was a trend towards older age [69.5 (57-78) vs. 49 (44-78) years] in the thrombolysis group (n = 6) compared to placebo (n = 6). Regarding feasibility, hospital arrival to treatment delay was above the allowed 2 h in three patients (25%). There were two protocol violations (17%) regarding PCT, both underestimating the predicted infarct in patients randomized in the placebo group. No symptomatic hemorrhage or death occurred during the first 7 days. Three of the four (75%) and one of the five (20%) patients were recanalized in the thrombolysis and placebo group respectively. The volume of non-infarcted at-risk tissue was 84 (44-206) cm(3) in the treatment arm and 29 (8-105) cm(3) in the placebo arm. CONCLUSIONS This pilot study shows that a randomized PCT-guided thrombolysis trial in patients with stroke of unknown onset may be feasible if issues such as treatment delays and reliable identification of tissue at risk of infarction tissue are resolved. Safety and efficiency of such an approach need to be established.
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Affiliation(s)
- Patrik Michel
- Department of Neurology Service, Center Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
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Mackey J, Kleindorfer D, Sucharew H, Moomaw CJ, Kissela BM, Alwell K, Flaherty ML, Woo D, Khatri P, Adeoye O, Ferioli S, Khoury JC, Hornung R, Broderick JP. Population-based study of wake-up strokes. Neurology 2011; 76:1662-7. [PMID: 21555734 DOI: 10.1212/wnl.0b013e318219fb30] [Citation(s) in RCA: 171] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Previous studies have estimated that wake-up strokes comprise 8%to 28% of all ischemic strokes, but these studies were either small or not population-based. We sought to establish the proportion and event rate of wake-up strokes in a large population-based study and to compare patients who awoke with stroke symptoms with those who were awake at time of onset. METHODS First-time and recurrent ischemic strokes among residents of the Greater Cincinnati/Northern Kentucky region (population 1.3 million) in 2005 were identified using International Classification of Diseases-9 codes 430-436 and verified via study physician review. Ischemic strokes in patients aged 18 years and older presenting to an emergency department were included. Baseline characteristics were ascertained, along with discharge modified Rankin Scale scores and 90-day mortality. RESULTS We identified 1,854 ischemic strokes presenting to an emergency department, of which 273 (14.3%) were wake-up strokes. There were no differences between wake-up strokes and all other strokes with regard to clinical features or outcomes except for minor differences in age and baseline retrospective NIH Stroke Scale score. The adjusted wake-up stroke event rate was 26.0/100,000. Of the wake-up strokes, at least 98 (35.9%) would have been eligible for thrombolysis if arrival time were not a factor. CONCLUSIONS Within our population, approximately 14% of ischemic strokes presenting to an emergency department were wake-up strokes. Wake-up strokes cannot be distinguished from other strokes by clinical features or outcome. We estimate that approximately 58,000 patients with wake-up strokes presented to an emergency department in the United States in 2005.
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Affiliation(s)
- J Mackey
- University of Cincinnati, Department of Neurology, Cincinnati, OH 45219, USA.
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Breuer L, Köhrmann M. Treatment for ischaemic stroke within an unknown time window: how much imaging do we need? Eur J Neurol 2011; 18:933-4. [DOI: 10.1111/j.1468-1331.2011.03349.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kim BJ, Lee SH, Shin CW, Ryu WS, Kim CK, Yoon BW. Ischemic stroke during sleep: its association with worse early functional outcome. Stroke 2011; 42:1901-6. [PMID: 21546480 DOI: 10.1161/strokeaha.110.602243] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Approximately one fourth of stroke occur during sleep. Despite the clinical and radiological similarities between wake-up stroke (WUS) and non-WUS, the functional outcomes of WUS are largely unknown. METHODS This retrospective analysis reviewed 2289 consecutive patients with acute ischemic stroke who were admitted between November 2002 and December 2009. We used 3 end-point analytic techniques to evaluate the association between WUS and functional outcomes: dichotomized analysis for "functional dependency" (a discharge modified Rankin Scale [mRS] score ≥2 regardless of initial stroke severity), severity-adjusted responder analysis for "unfavorable outcome" (a discharge mRS ≥1 for an admission National Institutes of Health Stroke Scale score 0 to 7; mRS ≥2 for National Institutes of Health Stroke Scale 8 to 14; or mRS ≥3 for National Institutes of Health Stroke Scale ≥15), and shift analysis for changes in overall distributions of discharge mRS scores. RESULTS The initial National Institutes of Health Stroke Scale score of patients with WUS was significantly higher than that of their non-WUS counterparts (median [interquartile range]; 4 [2 to 7] versus 3 [1 to 6]; P<0.01). The dichotomized analysis strategy failed to detect a significant association between WUS and functional dependency at discharge (adjusted OR, 0.99; 95% CI, 0.76 to 1.28). However, the responder analysis showed that patients with WUS were more likely to have "unfavorable outcomes" (adjusted OR, 1.33; 95% CI, 1.02 to 1.72), and the shift analysis also detected significant effect of WUS on the mRS score distributions toward increased dependency (adjusted OR, 1.22; 95% CI, 1.01 to 1.48). CONCLUSIONS From our study, we documented that WUS was associated with worse short-term outcomes after ischemic stroke. Careful selection of appropriate analytic techniques may help to detect modest associations in observational studies.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology, Seoul National University Hospital, 101 Daehang-ro, Jongno-gu, 110-744, Seoul, Republic of Korea
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Abstract
Stroke is a leading cause of death and adult morbidity worldwide. By defining stroke symptom onset by the time the patient was last known to be well, many patients whose onsets are unwitnessed are automatically ineligible for thrombolytic therapy. Advanced brain imaging may serve as a substitute witness to estimate stroke onset and duration in those patients who do not have a human witness. This article reviews and compares some of these imaging-based approaches to thrombolysis eligibility, which can potentially expand the use of thrombolytic therapy to a broader population of acute stroke patients.
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Affiliation(s)
- Ona Wu
- Department of Radiology, MGH/MIT/HMS Athinoula A. Martinos Center for Biomedical Imaging, MGH, 149 Thirteenth Street Suite 2301, Charlestown, MA 02129, USA.
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Kuruvilla A, Norris GM, Xavier AR. Acute endovascular recanalization therapy in wake-up stroke. J Neurol Sci 2011; 300:148-50. [DOI: 10.1016/j.jns.2010.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Revised: 09/28/2010] [Accepted: 10/26/2010] [Indexed: 10/18/2022]
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Prospective Acute Ischemic Stroke Outcomes After Endovascular Therapy: A Real-World Experience. World Neurosurg 2010; 74:455-64. [DOI: 10.1016/j.wneu.2010.06.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Accepted: 06/17/2010] [Indexed: 11/22/2022]
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Huisa BN, Raman R, Ernstrom K, Tafreshi G, Stemer A, Meyer BC, Hemmen T. Alberta Stroke Program Early CT Score (ASPECTS) in patients with wake-up stroke. J Stroke Cerebrovasc Dis 2010; 19:475-9. [PMID: 20719536 DOI: 10.1016/j.jstrokecerebrovasdis.2010.03.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 03/15/2010] [Accepted: 03/30/2010] [Indexed: 11/28/2022] Open
Abstract
One-quarter of ischemic strokes occur during sleep, and affected patients are excluded from thrombolytic therapy because of an unknown time of stroke onset. It has been suggested that early ischemic changes detected on computed tomography (CT) are similar in patients with acute stroke and patients who recently awoke with stroke. We compared head CT scans using the Alberta Stroke Program Early CT Score (ASPECTS) in patients who were likely to suffer their stroke during sleep (awoke group) and a control group of patients with stroke of known onset time. Patients were recruited from a prospectively collected acute stroke database. The awoke group was defined as all ischemic stroke patients who were "last seen normal" more than 4 hours ago, arrived between 4 a.m. and 10 a.m., and underwent head CT within 15 hours of the time last seen normal. The control group was randomly selected from patients who underwent head CT within 4 hours of stroke onset. The ASPECTS evaluations were performed by investigators blinded to patient group and time of onset. A modified Rankin Scale (mRS) score was available in 15 awoke patients and 46 control patients at 90 days after stroke. Twenty-eight awoke patients and 68 control patients had suitable imaging for the ASPECTS. Baseline demographic characteristics and risk factors were similar in the 2 groups. The dichotomized ASPECTS analysis (≤7 vs 8-10) showed no significant differences between the groups. ASPECTS was 8-10 in 89.3% the awoke group and 95.6% in the control group (P=.353). There was a trend toward higher 90-day mRS score (0-1) in the awoke group versus controls (73% vs 45%; P=.079). Initial ASPECTS was similar in patients with wake-up stroke and those with 4 hours of symptoms. This suggests that a subset of wake-up stroke patients might be suitable for thrombolytic therapy.
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Affiliation(s)
- Branko N Huisa
- Department of Neurosciences, University of California San Diego, San Diego, California 92103-8466, USA.
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Breuer L, Schellinger PD, Huttner HB, Halwachs R, Engelhorn T, Doerfler A, Köhrmann M. Feasibility and safety of magnetic resonance imaging-based thrombolysis in patients with stroke on awakening: initial single-centre experience. Int J Stroke 2010; 5:68-73. [PMID: 20446939 DOI: 10.1111/j.1747-4949.2010.00410.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Up to 25% of all acute ischaemic strokes occur during sleep. Because of the unclear time window, patients with stroke on awakening are usually not considered for acute therapy and excluded from most acute treatment trials. AIM To evaluate the feasibility of magnetic resonance imaging-based intravenous thrombolysis in patients with stroke on awakening in a routine clinical setting. METHODS Forty-five patients with stroke on awakening clinically qualifying for intravenous thrombolysis and presenting within 6 h after symptom recognition were admitted to our institution between October 2006 and May 2008. Following an institutional protocol, patients received magnetic resonance imaging as a first-line imaging modality and were offered mismatch-based thrombolysis whenever possible. Baseline demographic data, clinical, laboratory and imaging findings were analysed. Outcome was assessed using the modified Rankin Scale score at 3 months. RESULTS Magnetic resonance imaging screening was feasible in 43/45 patients (96%). After screening, 10 patients (22%) were treated with intravenous thrombolysis. There were no differences between treated and untreated patients regarding cardiovascular risk factors, stroke aetiology, previous prophylactic treatment and symptom recognition to door time or door to imaging time. Outcome was comparable in both groups despite a trend towards more severe strokes in the intravenous thrombolysis group. Only one asymptomatic and no symptomatic haemorrhage were observed. CONCLUSION Our data demonstrate that magnetic resonance imaging-based thrombolysis is feasible and possibly safe in patients with stroke on awakening (SOA). Randomised clinical trials for patients with stroke on awakening are needed to further test the safety and efficacy of intravenous thrombolysis in this patient group. The results of our study may help to initiate and design such studies.
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Affiliation(s)
- L Breuer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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