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Kim DY, Park TH, Cho YJ, Park JM, Lee K, Lee M, Lee J, Bae SY, Hong DY, Jung H, Ko E, Guk HS, Kim BJ, Kim JY, Kang J, Han MK, Park SS, Hong KS, Park HK, Lee JY, Lee BC, Yu KH, Oh MS, Kim DE, Gwak DS, Lee SJ, Kim JG, Lee J, Kwon DH, Cha JK, Kim DH, Kim JT, Choi KH, Kim H, Choi JC, Kim JG, Kang CH, Sohn SI, Hong JH, Park H, Lee SH, Kim C, Shin DI, Yum KS, Kang K, Park KY, Jeong HB, Park CY, Lee KJ, Kwon JH, Kim WJ, Lee JS, Bae HJ. Contemporary Statistics of Acute Ischemic Stroke and Transient Ischemic Attack in 2021: Insights From the CRCS-K-NIH Registry. J Korean Med Sci 2024; 39:e278. [PMID: 39228188 PMCID: PMC11372415 DOI: 10.3346/jkms.2024.39.e278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 08/07/2024] [Indexed: 09/05/2024] Open
Abstract
This report presents the latest statistics on the stroke population in South Korea, sourced from the Clinical Research Collaborations for Stroke in Korea-National Institute for Health (CRCS-K-NIH), a comprehensive, nationwide, multicenter stroke registry. The Korean cohort, unlike western populations, shows a male-to-female ratio of 1.5, attributed to lower risk factors in Korean women. The average ages for men and women are 67 and 73 years, respectively. Hypertension is the most common risk factor (67%), consistent with global trends, but there is a higher prevalence of diabetes (35%) and smoking (21%). The prevalence of atrial fibrillation (19%) is lower than in western populations, suggesting effective prevention strategies in the general population. A high incidence of large artery atherosclerosis (38%) is observed, likely due to prevalent intracranial arterial disease in East Asians and advanced imaging techniques. There has been a decrease in intravenous thrombolysis rates, from 12% in 2017-2019 to 10% in 2021, with no improvements in door-to-needle and door-to-puncture times, worsened by the coronavirus disease 2019 pandemic. While the use of aspirin plus clopidogrel for non-cardioembolic stroke and direct oral anticoagulants for atrial fibrillation is well-established, the application of direct oral anticoagulants for non-atrial fibrillation cardioembolic strokes in the acute phase requires further research. The incidence of early neurological deterioration (13%) and the cumulative incidence of recurrent stroke at 3 months (3%) align with global figures. Favorable outcomes at 3 months (63%) are comparable internationally, yet the lack of improvement in dependency at 3 months highlights the need for advancements in acute stroke care.
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Affiliation(s)
- Do Yeon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Yong-Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jong-Moo Park
- Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Korea
| | - Kyungbok Lee
- Department of Neurology, Soonchunhyang University Hospital Seoul, Seoul, Korea
| | - Minwoo Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Sang Yoon Bae
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Da Young Hong
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Hannah Jung
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Eunvin Ko
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Hyung Seok Guk
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jun Yup Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jihoon Kang
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Moon-Ku Han
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jeong-Yoon Lee
- Department of Neurology, Soonchunhyang University Hospital Seoul, Seoul, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Dong-Seok Gwak
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University, School of Medicine, Daejeon Eulji Medical Center, Daejeon, Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University, School of Medicine, Daejeon Eulji Medical Center, Daejeon, Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Medical Center, Daegu, Korea
| | - Doo Hyuk Kwon
- Department of Neurology, Yeungnam University Medical Center, Daegu, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Hyunsoo Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
| | - Joong-Goo Kim
- Department of Neurology, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
| | - Chul-Hoo Kang
- Department of Neurology, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Sang-Hwa Lee
- Department of Neurology, Chuncheon Sacred Heart Hospital, Chuncheon, Korea
| | - Chulho Kim
- Department of Neurology, Chuncheon Sacred Heart Hospital, Chuncheon, Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Kyu Sun Yum
- Department of Neurology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Kwang-Yeol Park
- Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
| | - Hae-Bong Jeong
- Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
| | - Chan-Young Park
- Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
| | - Keon-Joo Lee
- Department of Neurology, Korea University Guro Hospital, Seoul, Korea
| | - Jee Hyun Kwon
- Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
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Claudi C, Worm A, Schmohl D, Juenemann M, Alhaj Omar O, Loesche H, Huttner HB, Schramm P. FAST4D-A New Score to Reduce Missed Strokes in Emergency Medical Service: A Prospective, Multicentric Observational Proof-of-Concept Trial. J Clin Med 2024; 13:5033. [PMID: 39274246 PMCID: PMC11396033 DOI: 10.3390/jcm13175033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Revised: 08/20/2024] [Accepted: 08/23/2024] [Indexed: 09/16/2024] Open
Abstract
Background: Undoubtedly, overlooking a stroke can result in severe disability or even death. However, identifying stroke patients in the prehospital setting poses a significant challenge. While the Face-Arm-Speech-Time (FAST) score is widely used, its effectiveness has been questioned because of its focus on symptoms primarily associated with anterior circulation strokes. In response to this limitation, we developed the innovative FAST4D score and conducted a comparative analysis of stroke detection rates between the novel FAST4D score and the FAST score. Methods: This prospective, multicenter proof-of-concept study aimed to assess stroke detection rates using both the FAST score and the new FAST4D score, which incorporates additional items such as the acute onset of diplopic images, deficit in the field of vision, dizziness/vertigo, and dysmetria/ataxia. Following their presentation to emergency medical services, all patients suspected of having a stroke and those diagnosed with a stroke upon discharge were included in this study. The diagnostic performance of the novel FAST4D score was evaluated and compared with that of the FAST score. Results: Between May 2019 and June 2021, a total of 1469 patients (749 female) were enrolled, with 1035 patients discharged with the diagnosis of stroke. Notably, 259 patients were identified solely through the FAST4D score. This resulted in a significantly higher rate of correctly identified as having had a stroke (stroke detection rate, sensitivity) with the new FAST4D score (93%) compared with the established FAST score (78%) (p < 0.001). This resulted in a reduction in false negative diagnoses by 65%. Conclusions: The novel FAST4D score demonstrated a 15-percentage increase in the stroke detection rate. This heightened detection rate holds the potential for more accurate patient allocation to stroke units, consequently reducing the time to revascularization.
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Affiliation(s)
- Christian Claudi
- Department of Neurology, University Hospital of the Justus-Liebig-University Giessen, 35385 Giessen, Germany
| | - André Worm
- Department of Neurology, University Hospital of the Justus-Liebig-University Giessen, 35385 Giessen, Germany
| | - Donata Schmohl
- Department of Emergency Medicine, Campus Lippe, University Hospital of Bielefeld, 33615 Bielefeld, Germany
| | - Martin Juenemann
- Department of Neurology, University Hospital of the Justus-Liebig-University Giessen, 35385 Giessen, Germany
| | - Omar Alhaj Omar
- Department of Neurology, University Hospital of the Justus-Liebig-University Giessen, 35385 Giessen, Germany
| | - Hendrik Loesche
- Emergency Medical Service Educational Center of Malteser, District of Hesse, Rhineland Palatinate and Saarland, 35578 Wetzlar, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital of the Justus-Liebig-University Giessen, 35385 Giessen, Germany
| | - Patrick Schramm
- Department of Neurology, University Hospital of the Justus-Liebig-University Giessen, 35385 Giessen, Germany
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Katsanos AH, Poppe A, Swartz RH, Mandzia J, Catanese L, Shankar J, Yip S, Verreault S, Medvedev G, Maran I, Legault C, Ferguson D, Archer B, Bharatha A, Volders D, Kelly M, Carpani F, Pikula A, Tkach A, Moreau F, Beaudry M, Appireddy R, Deshmukh A, Almekhlafi M, Fahed R, Kamal N, Menon B, Shoamanesh A, Williams H, Yu AYX, Heran MKS, Hill MD, Sharma M, Earl K, Demchuk AM, Stotts G. Interhospital Transfer for Endovascular Stroke Treatment in Canada: Results From the OPTIMISE Registry. Stroke 2024; 55:2103-2112. [PMID: 39038099 DOI: 10.1161/strokeaha.124.046690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 06/12/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Interhospital transfer for patients with stroke due to large vessel occlusion for endovascular thrombectomy (EVT) has been associated with treatment delays. METHODS We analyzed data from Optimizing Patient Treatment in Major Ischemic Stroke With EVT, a quality improvement registry to support EVT implementation in Canada. We assessed for unadjusted differences in baseline characteristics, time metrics, and procedural outcomes between patients with large vessel occlusion transferred for EVT and those directly admitted to an EVT-capable center. RESULTS Between January 1, 2018, and December 31, 2021, a total of 6803 patients received EVT at 20 participating centers (median age, 73 years; 50% women; and 50% treated with intravenous thrombolysis). Patients transferred for EVT (n=3376) had lower rates of M2 occlusion (22% versus 27%) and higher rates of basilar occlusion (9% versus 5%) compared with those patients presenting directly at an EVT-capable center (n=3373). Door-to-needle times were shorter in patients receiving intravenous thrombolysis before transfer compared with those presenting directly to an EVT center (32 versus 36 minutes). Patients transferred for EVT had shorter door-to-arterial access times (37 versus 87 minutes) but longer last seen normal-to-arterial access times (322 versus 181 minutes) compared with those presenting directly to an EVT-capable center. No differences in arterial access-to-reperfusion times, successful reperfusion rates (85% versus 86%), or adverse periprocedural events were found between the 2 groups. Patients transferred to EVT centers had a similar likelihood for good functional outcome (modified Rankin Scale score, 0-2; 41% versus 43%; risk ratio, 0.95 [95% CI, 0.88-1.01]; adjusted risk ratio, 0.98 [95% CI, 0.91-1.05]) and a higher risk for all-cause mortality at 90 days (29% versus 25%; risk ratio, 1.15 [95% CI, 1.05-1.27]; adjusted risk ratio, 1.14 [95% CI, 1.03-1.28]) compared with patients presenting directly to an EVT center. CONCLUSIONS Patients transferred for EVT experience significant delays from the time they were last seen normal to the initiation of EVT.
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Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada (A.H.K., L.C., A.S., M.S.)
| | - Alexandre Poppe
- Department of Neurosciences, Université de Montréal and Centre Hospitalier de l'Université de Montréal, QC, Canada (A. Poppe)
| | - Rick H Swartz
- Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (R.H.S., A.Y.X.Y.)
| | - Jennifer Mandzia
- Department of Clinical Neurological Sciences, London Health Sciences Centre and Western University, ON, Canada (J.M.)
| | | | - Jai Shankar
- Department of Radiology, University of Manitoba, Winnipeg, Canada (J.S.)
| | - Samuel Yip
- Division of Neurology (S.Y.), The University of British Columbia, Vancouver, Canada
| | - Steve Verreault
- CHU de Québec, Hôpital de l'Enfant-Jésus, Montreal, Canada (S.V.)
| | - George Medvedev
- University of British Columbia and the Fraser Health Authority, New Westminster, Canada (G.M.)
| | - Ilavarasy Maran
- Department of Neurology, Trillium Health Partners, Missisauga, ON, Canada (I.M.)
| | - Catherine Legault
- Division of Neurology, McGill University Health Centre, Montreal, QC, Canada (C.L.)
| | - Darren Ferguson
- Department of Diagnostic Radiology, Dalhousie University, Saint John, NB, Canada (D.F., B.A.)
| | - Brian Archer
- Department of Diagnostic Radiology, Dalhousie University, Saint John, NB, Canada (D.F., B.A.)
| | - Aditya Bharatha
- Department of Medical Imaging, St. Michael's Hospital, Unity Health Toronto, University of Toronto, ON, Canada (A.B.)
| | - David Volders
- Diagnostic Imaging, Dalhousie University, Halifax, NS, Canada (D.V.)
| | - Michael Kelly
- Department of Neurosurgery, University of Saskatchewan, Saskatoon, Canada (M.K.)
| | - Federico Carpani
- Toronto Western Hospital and the University of Toronto, ON, Canada (F.C., A. Pikula)
| | - Aleksandra Pikula
- Toronto Western Hospital and the University of Toronto, ON, Canada (F.C., A. Pikula)
| | | | | | - Michel Beaudry
- Centre de santé et de services sociaux de Chicoutimi, Saguenay, QC, Canada (M.B.)
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada (R.A.)
| | - Aviraj Deshmukh
- Division of Clinical Sciences, Health Sciences North, Northern Ontario School of Medicine, Sudbury, ON, Canada (A.D.)
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (M.A., B.M., M.D.H., A.M.D.)
| | - Robert Fahed
- Division of Neurology, Department of Medicine, The Ottawa Hospital, ON, Canada (R.F., G.S.)
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada (N.K.)
| | - Bijoy Menon
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (M.A., B.M., M.D.H., A.M.D.)
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada (A.H.K., L.C., A.S., M.S.)
| | | | - Amy Y X Yu
- Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (R.H.S., A.Y.X.Y.)
| | - Manraj K S Heran
- Department of Radiology (M.K.S.H.), The University of British Columbia, Vancouver, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (M.A., B.M., M.D.H., A.M.D.)
| | - Mukul Sharma
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada (A.H.K., L.C., A.S., M.S.)
| | - Karen Earl
- Canadian Stroke Consortium, Oakville, ON (K.E.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (M.A., B.M., M.D.H., A.M.D.)
| | - Grant Stotts
- Division of Neurology, Department of Medicine, The Ottawa Hospital, ON, Canada (R.F., G.S.)
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Checkouri T, Sablot D, Varnier Q, Fryder I, Collemiche FL, Azais B, Dargazanli C, Leibinger F, Cagnazzo F, Mahmoudi M, Lefevre PH, Van Damme L, Gascou G, Schmidt J, Arquizan C, Plantard C, Farouil G, Costalat V. Becoming a thrombectomy-capable stroke center: Clinical and medico-economical effectiveness at the hospital level. Eur Stroke J 2024:23969873241254239. [PMID: 38760934 DOI: 10.1177/23969873241254239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2024] Open
Abstract
INTRODUCTION Too few patients benefit from endovascular therapy (EVT) in large vessel occlusion acute stroke (LVOS), and various acute stroke care paradigms are currently investigated to reduce these inequalities in health access. We aimed to investigate whether newly set-up thrombectomy-capable stroke centers (TSC) offered a safe, effective and cost-effective procedure. PATIENTS AND METHODS This French retrospective study compared the outcomes of LVOS patients with an indication for EVT and treated at the Perpignan hospital before on-site thrombectomy was available (Primary stroke center), and after formation of local radiology team for neurointervention (TSC). Primary endpoints were 3-months functional outcomes, assessed by the modified Rankin scale. Various safety endpoints for ischemic and hemorragic procedural complications were assessed. We conducted a medico-economic analysis to estimate the cost-benefit of becoming a TSC for the hospital. RESULTS The differences between 422 patients in the PSC and 266 in the TSC were adjusted by the means of weighted logistic regression. Patients treated in the TSC had higher odds of excellent functional outcome (aOR 1.77 [1.16-2.72], p = 0.008), with no significant differences in the rates of procedural complications. The TSC setting shortened onset-to-reperfusion times by 144 min (95% CI [131-155]; p < 0.0001), and was cost-effective after 21 treated LVOS patients. On-site thrombectomy saves 10.825€ per patient for the hospital. DISCUSSION Our results demonstrate that the TSC setting improves functional outcomes and reduces intra-hospital costs in LVOS patients. TSCs could play a major public health role in acute stroke care and access to EVT.
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Affiliation(s)
- Thomas Checkouri
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Denis Sablot
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Quentin Varnier
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Ivan Fryder
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | | | - Benoit Azais
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | | | - Federico Cagnazzo
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Mehdi Mahmoudi
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | | | | | - Gregory Gascou
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Julia Schmidt
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier, France
| | - Carole Plantard
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | | | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
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5
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Li S, Wang X, Jin A, Liu G, Gu H, Li H, Campbell BCV, Fisher M, Yang Y, Wei Y, Wang J, Wang Y, Zhao X, Liu L, Li Z, Meng X, Wang Y. Safety and Efficacy of Reteplase Versus Alteplase for Acute Ischemic Stroke: A Phase 2 Randomized Controlled Trial. Stroke 2024; 55:366-375. [PMID: 38152962 DOI: 10.1161/strokeaha.123.045193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/05/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Reteplase is a more affordable new-generation thrombolytic with a prolonged half-life. We aimed to determine the safety dose range of reteplase for patients with acute ischemic stroke within 4.5 hours of onset. METHODS This is a multicenter, prospective, randomized controlled, open-label, blinded-end point phase 2 clinical trial. Patients with acute ischemic stroke aged between 18 and 80 years who were eligible for standard intravenous thrombolysis were enrolled from 17 centers in China and randomly assigned (1:1:1) to receive intravenous reteplase 12+12 mg, intravenous reteplase 18+18 mg, or intravenous alteplase 0.9 mg/kg. The primary safety outcome was symptomatic intracranial hemorrhage (SITS definition) within 36 hours. The primary efficacy outcome was the proportion of patients with the National Institutes of Health Stroke Scale score of no more than 1 or a decrease of at least 4 points from the baseline at 14 days after thrombolysis. RESULTS Between August 2019 and May 2021, 180 patients were randomly assigned to reteplase 12+12 mg (n=61), reteplase 18+18 mg (n=67), or alteplase (n=52). Four patients did not receive the study agent. Symptomatic intracranial hemorrhage occurred in 3 of 60 (5.0%) in the reteplase 12+12 mg group, 1 of 66 (1.5%) in the reteplase 18+18 mg group, and 1 of 50 (2.0%) in the alteplase group (P=0.53). The primary efficacy outcome in the modified intention-to-treat population occurred in 45 of 60 (75.0%) in the reteplase 12+12 mg group (odds ratio, 0.85 [95% CI, 0.35-2.06]), 48 of 66 (72.7%) in the reteplase 18+18 mg group (odds ratio, 0.75 [95% CI, 0.32-1.78]), and 39 of 50 (78.0%) in alteplase group. CONCLUSIONS Reteplase was well tolerated in patients with acute ischemic stroke within 4.5 hours of onset in China with a similar efficacy profile to alteplase. The efficacy and appropriate dosage of reteplase for patients with acute ischemic stroke need prospective validation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04028518.
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Affiliation(s)
- Shuya Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Xuechun Wang
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Aoming Jin
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Gaifen Liu
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Hongqiu Gu
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Hao Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, VIC, Australia (B.C.V.C.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | - Yi Yang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China (Y.Y.)
| | - Yan Wei
- Department of Neurology, Halison International Peace Hospital of Hengshui City, China (Y.W.)
| | - Junhai Wang
- Department of Neurology, Sinopharm Tongmei General Hospital, Datong, China (J.W.)
| | - Yilong Wang
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Xingquan Zhao
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Liping Liu
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Zixiao Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Xia Meng
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Yongjun Wang
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
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Stein LK, Maillie L, Erdman J, Loebel E, Mayman N, Sharma A, Wolmer S, Tuhrim S, Fifi JT, Jette N, Mocco J, Dhamoon MS. Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence. J Neurointerv Surg 2024; 16:151-155. [PMID: 37068938 PMCID: PMC11192062 DOI: 10.1136/jnis-2023-020128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/02/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Although national organizations recognize the importance of regionalized acute ischemic stroke (AIS) care, data informing expansion are sparse. We assessed real-world regional variation in emergent AIS treatment, including growth in revascularization therapies and stroke center certification. We hypothesized that we would observe overall growth in revascularization therapy utilization, but observed differences would vary greatly regionally. METHODS A retrospective cross-sectional analysis was carried out of de-identified national inpatient Medicare Fee-for-Service datasets from 2016 to 2019. We identified AIS admissions and treatment with thrombolysis and endovascular thrombectomy (ET) with International Classification of Diseases, 10th Revision, Clinical Modification codes. We grouped hospitals in Dartmouth Atlas of Healthcare Hospital Referral Regions (HRR) and calculated hospital, demographic, and acute stroke treatment characteristics for each HRR. We calculated the percent of hospitals with stroke certification and AIS cases treated with thrombolysis or ET per HRR. RESULTS There were 957 958 AIS admissions. Relative mean (SD) growth in percent of AIS admissions receiving revascularization therapy per HRR from 2016 to 2019 was 13.4 (31.7)% (IQR -6.1-31.7%) for thrombolysis and 28.0 (72.0)% (IQR 0-56.0%) for ET. The proportion of HRRs with decreased or no difference in ET utilization was 38.9% and the proportion of HRRs with decreased or no difference in thrombolysis utilization was 32.7%. Mean (SD) stroke center certification proportion across HRRs was 45.3 (31.5)% and this varied widely (IQR 18.3-73.4%). CONCLUSIONS Overall growth in AIS treatment has been modest and, within HRRs, growth in AIS treatment and the proportion of centers with stroke certification varies dramatically.
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Affiliation(s)
- Laura K Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Luke Maillie
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Erdman
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Emma Loebel
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Naomi Mayman
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Akarsh Sharma
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Stanley Tuhrim
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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7
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Ungerer MN, Bartig D, Richter D, Krogias C, Hacke W, Gumbinger C. The evolution of acute stroke care in Germany from 2019 to 2021: analysis of nation-wide administrative datasets. Neurol Res Pract 2024; 6:4. [PMID: 38200611 PMCID: PMC10782681 DOI: 10.1186/s42466-023-00297-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/05/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND The treatment of ischemic stroke (IS) has changed considerably in recent years. Particularly the advent of mechanical thrombectomy (MTE) has revolutionized the available treatment options. Most patients in developed countries have access to intravenous thrombolysis (IVT). However access to MTE remains restricted in some regions despite efforts to increase its availability. We performed an evaluation of national datasets to monitor improvements made in access to revascularization therapies for IS patients in Germany. METHODS We analyzed national datasets on German Diagnosis-Related Groups and structured quality reports by extracting information of patients admitted with stroke with and without IVT and MTE for the period of 2019-2021. Data from 2016 and limited data for 2022 were also included for comparison. RESULTS Admissions with ischemic stroke declined during the years of the COVID 19 pandemic by 4.5% from 227,258 in 2019 to 216,923 in 2021. IVT rates were stable with 16.3% being treated with IVT in 2019 and 2021. MTE rates continued to increase from 7.1 to 8.4% and the number of MTE centers increased by 14.8% in the same period. Over 87.3% of MTEs were performed in centers with a case volume exceeding 50 cases per year in 2021. The largest increase in the relative share of MTEs was seen in large MTE centers (n ≥ 200). Patient age for MTEs surpassed the age for IVTs in 2019 and the proportion of patients ≥ 80 years receiving MTE continued to increase. The proportion of regions in Germany with poor MTE rates (≤ 4.1%) decreased significantly from 2019 (12.3%) to 2021 (5.3%) (p < 0.001). CONCLUSIONS We found strong evidence that while IVT rates reached a temporary ceiling effect, both the absolute number of and access to MTEs continued to increase in Germany. Regional disparities have become less significant and the majority of MTEs are performed in centers with medium or high case volumes.
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Affiliation(s)
- Matthias N Ungerer
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
| | | | - Daniel Richter
- Department of Neurology, Evangelisches Krankenhaus Herne, Academic Teaching Hospital of the Ruhr-University Bochum, Herne, Germany
| | - Christos Krogias
- Department of Neurology, Evangelisches Krankenhaus Herne, Academic Teaching Hospital of the Ruhr-University Bochum, Herne, Germany
| | - Werner Hacke
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Gumbinger
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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8
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Akay EMZ, Rieger J, Schöttler R, Behland J, Schymczyk R, Khalil AA, Galinovic I, Sobesky J, Fiebach JB, Madai VI, Hilbert A, Frey D. A deep learning analysis of stroke onset time prediction and comparison to DWI-FLAIR mismatch. Neuroimage Clin 2023; 40:103544. [PMID: 38000188 PMCID: PMC10709350 DOI: 10.1016/j.nicl.2023.103544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/27/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023]
Abstract
INTRODUCTION When time since stroke onset is unknown, DWI-FLAIR mismatch rating is an established technique for patient stratification. A visible DWI lesion without corresponding parenchymal hyperintensity on FLAIR suggests time since onset of under 4.5 h and thus a potential benefit from intravenous thrombolysis. To improve accuracy and availability of the mismatch concept, deep learning might be able to augment human rating and support decision-making in these cases. METHODS We used unprocessed DWI and coregistered FLAIR imaging data to train a deep learning model to predict dichotomized time since ischemic stroke onset. We analyzed the performance of Group Convolutional Neural Networks compared to other deep learning methods. Unlabeled imaging data was used for pre-training. Prediction performance of the best deep learning model was compared to the performance of four independent junior and senior raters. Additionally, in cases deemed indeterminable by human raters, model ratings were used to augment human performance. Post-hoc gradient-based explanations were analyzed to gain insights into model predictions. RESULTS Our best predictive model performed comparably to human raters. Using model ratings in cases deemed indeterminable by human raters improved rating accuracy and interrater agreement for junior and senior ratings. Post-hoc explainability analyses showed that the model localized stroke lesions to derive predictions. DISCUSSION Our analysis shows that deep learning based clinical decision support has the potential to improve the accessibility of the DWI-FLAIR mismatch concept by supporting patient stratification.
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Affiliation(s)
- Ela Marie Z Akay
- Charité Lab for Artificial Intelligence in Medicine (CLAIM), Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Jana Rieger
- Charité Lab for Artificial Intelligence in Medicine (CLAIM), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ricardo Schöttler
- Charité Lab for Artificial Intelligence in Medicine (CLAIM), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jonas Behland
- Charité Lab for Artificial Intelligence in Medicine (CLAIM), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Raphael Schymczyk
- Charité Lab for Artificial Intelligence in Medicine (CLAIM), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ahmed A Khalil
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Ivana Galinovic
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Sobesky
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Vince I Madai
- QUEST Center for Responsible Research, Berlin Institute of Health (BIH), Charité Universitätsmedizin Berlin, Berlin, Germany; Faculty of Computing, Engineering and the Built Environment, School of Computing and Digital Technology, Birmingham City University, Birmingham, United Kingdom
| | - Adam Hilbert
- Charité Lab for Artificial Intelligence in Medicine (CLAIM), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Dietmar Frey
- Charité Lab for Artificial Intelligence in Medicine (CLAIM), Charité Universitätsmedizin Berlin, Berlin, Germany
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Kollmar R, De Georgia M. Milestones in the history of neurocritical care. Neurol Res Pract 2023; 5:43. [PMID: 37559106 PMCID: PMC10413505 DOI: 10.1186/s42466-023-00271-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023] Open
Abstract
Over the last century, significant milestones have been achieved in managing critical illness and diagnosing and treating neurological diseases. Building upon these milestones, the field of neurocritical care emerged in the 1980 and 1990 s at the convergence of critical care medicine and acute neurological treatment. This comprehensive review presents a historical account of key developments in neurocritical care in both the United States and Europe, with a special emphasis on German contributions. The scope of the review encompasses: the foundations of neurocritical care, including post-operative units in the 1920s and 30s, respiratory support during the poliomyelitis epidemics in the 40 and 50 s, cardiac and hemodynamic care in the 60 and 70 s, and stroke units in the 80 and 90 s; key innovations including cerebral angiography, computed tomography, and intracranial pressure and multi-modal monitoring; and advances in stroke, traumatic brain injury, cardiac arrest, neuromuscular disorders, meningitis and encephalitis. These advances have revolutionized the management of neurological emergencies, emphasizing interdisciplinary teamwork, evidence-based protocols, and personalized approaches to care.
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Affiliation(s)
- Rainer Kollmar
- Department of Neurology and Neurointensive Care, Darmstadt Academic Hospital, Darmstadt, Germany.
| | - Michael De Georgia
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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10
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Kunze R, Fischer S, Marti HH, Preissner KT. Brain alarm by self-extracellular nucleic acids: from neuroinflammation to neurodegeneration. J Biomed Sci 2023; 30:64. [PMID: 37550658 PMCID: PMC10405513 DOI: 10.1186/s12929-023-00954-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/22/2023] [Indexed: 08/09/2023] Open
Abstract
Neurological disorders such as stroke, multiple sclerosis, as well as the neurodegenerative diseases Parkinson's or Alzheimer's disease are accompanied or even powered by danger associated molecular patterns (DAMPs), defined as endogenous molecules released from stressed or damaged tissue. Besides protein-related DAMPs or "alarmins", numerous nucleic acid DAMPs exist in body fluids, such as cell-free nuclear and mitochondrial DNA as well as different species of extracellular RNA, collectively termed as self-extracellular nucleic acids (SENAs). Among these, microRNA, long non-coding RNAs, circular RNAs and extracellular ribosomal RNA constitute the majority of RNA-based DAMPs. Upon tissue injury, necrosis or apoptosis, such SENAs are released from neuronal, immune and other cells predominantly in association with extracellular vesicles and may be translocated to target cells where they can induce intracellular regulatory pathways in gene transcription and translation. The majority of SENA-induced signaling reactions in the brain appear to be related to neuroinflammatory processes, often causally associated with the onset or progression of the respective disease. In this review, the impact of the diverse types of SENAs on neuroinflammatory and neurodegenerative diseases will be discussed. Based on the accumulating knowledge in this field, several specific antagonistic approaches are presented that could serve as therapeutic interventions to lower the pathological outcome of the indicated brain disorders.
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Affiliation(s)
- Reiner Kunze
- Institute of Physiology and Pathophysiology, Department of Cardiovascular Physiology, Ruprecht-Karls-University, Im Neuenheimer Feld 326, 69120 Heidelberg, Germany
| | - Silvia Fischer
- Department of Biochemistry, Medical School, Justus-Liebig-University, Giessen, Germany
| | - Hugo H. Marti
- Institute of Physiology and Pathophysiology, Department of Cardiovascular Physiology, Ruprecht-Karls-University, Im Neuenheimer Feld 326, 69120 Heidelberg, Germany
| | - Klaus T. Preissner
- Department of Biochemistry, Medical School, Justus-Liebig-University, Giessen, Germany
- Kerckhoff-Heart-Research-Institute, Department of Cardiology, Medical School, Justus-Liebig-University, Giessen, Germany
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11
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Heinze M, Cheng B, Cho TH, Ebinger M, Endres M, Fiebach JB, Fiehler J, Puig J, Lemmens R, Thijs V, Muir KW, Nighoghossian N, Königsberg A, Jensen M, Barow E, Lettow I, Pedraza S, Simonsen CZ, Gerloff C, Thomalla G. Predictors of Early Neurological Improvement and Its Relationship to Thrombolysis Treatment and Long-Term Outcome in the WAKE-UP Study. Cerebrovasc Dis 2023; 52:560-566. [PMID: 36863328 DOI: 10.1159/000528805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/07/2022] [Indexed: 03/04/2023] Open
Abstract
INTRODUCTION The aims of this study were to evaluate the relationship of clinical and imaging baseline factors and treatment on the occurrence of early neurological improvement (ENI) in the WAKE-UP trial of MRI-guided intravenous thrombolysis in unknown onset stroke and to examine the association of ENI with long-term favorable outcome in patients treated with intravenous thrombolysis. METHODS We analyzed data from all patients with at least moderate stroke severity, reflected by an initial National Institutes of Health Stroke Scale (NIHSS) score ≥4 randomized in the WAKE-UP trial. ENI was defined as a decrease in NIHSS of ≥8 or a decline to zero or 1 at 24 h after initial presentation to the hospital. Favorable outcome was defined as a modified Rankin Scale score of 0-1 at 90 days. We performed group comparison and multivariable analysis of baseline factors associated with ENI and performed mediation analysis to evaluate the effect of ENI on the relationship between intravenous thrombolysis and favorable outcome. RESULTS ENI occurred in 93 out of 384 patients (24.2%) and was more likely to occur in patients who received treatment with alteplase (62.4% vs. 46.0%, p = 0.009), had smaller acute diffusion-weighted imaging lesion volume (5.51 mL vs. 10.9 mL, p ≤ 0.001), and less often large-vessel occlusion on initial MRI (7/93 [12.1%] versus 40/291 [29.9%], p = 0.014). In multivariable analysis, treatment with alteplase (OR 1.97, 95% confidence interval [CI] 0.954-1.100), lower baseline stroke volume (OR 0.965, 95% CI: 0.932-0.994), and shorter time from symptom recognition to treatment (OR 0.994, 95% CI: 0.989-0.999) were independently associated with ENI. Patients with ENI had higher rates of favorable outcome at 90-day follow-up (80.6% vs. 31.3%, p ≤ 0.001). The occurrence of ENI significantly mediated the association of treatment with a good outcome, with ENI at 24 h explaining 39.4% (12.9-96%) of the treatment effect. CONCLUSION Intravenous alteplase increases the odds of ENI in patients with at least moderate stroke severity, especially when given early. In patients with large-vessel occlusion, ENI is rarely observed without thrombectomy. ENI represents a good surrogate early marker of treatment effect as more than a third of good outcome at 90 days is explained by ENI at 24 h.
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Affiliation(s)
- Marlene Heinze
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
- Medical Park Berlin Humboldtmühle, Klinik für Neurologie, Berlin, Germany
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité -Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Centrum für Schlaganfallforschung Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Josep Puig
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr. Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt-Edifici M2, Girona, Spain
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, KU Leuven - University of Leuven, Experimental Neurology, Leuven, Belgium
- VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, University Avenue, Glasgow, UK
| | | | - Alina Königsberg
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ewgenia Barow
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Iris Lettow
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr. Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt-Edifici M2, Girona, Spain
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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12
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Ok T, Yoon PH, Kim GS, Seo KD. Improving the Prognosis of Patients With Acute Ischemic Stroke Treated in the Late Time Window After the Introduction of Advanced Imaging Software: Benefits From Thrombectomy in the Extended Time Window. J Korean Med Sci 2022; 37:e358. [PMID: 36573389 PMCID: PMC9792263 DOI: 10.3346/jkms.2022.37.e358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/13/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) of ischemic stroke was recommended as a clinical guideline in 2015, and the indication for time was expanded in 2018 based on two clinical studies. We aimed to compare and analyze the prognosis of patients treated under the extended time indication before and after the introduction of advanced software. METHODS We obtained data from medical records between 2016 to 2020. From 2016 to 2017, patients who did not receive MT who visited the hospital within 24 hours from the last normal time (LNT) were classified as standard medical treatment (SMT) group. Among patients who underwent MT between 2019 and 2020, patients who visited the hospital between 6-24 hours from the LNT were classified into the extended MT (EMT) group. Good outcome was defined as 3-months modified rankin scale (mRS) ≤ 2, and a poor outcome as mRS ≥ 4. RESULTS From 2016 to 2017, 1,058 patients were hospitalized for ischemic stroke, of which 60 (5.7%) received MT, and 27 patients were classified into the SMT group. Among 1,019 patients between 2019 and 2020, 85 (8.3%) received MT, and 24 patients were in the EMT group. Among the SMT group, only 3 had a good prognosis, and 24 (88.9%) had a poor prognosis. However, in the EMT group, 10 (41.7%) had a good prognosis, and 9 (37.5%) had a poor prognosis. The SMT group had a 49.1 times higher risk of poor prognosis compared to the EMT group (P = 0.008). CONCLUSION The number of patients with ischemic stroke who receive MT has increased by using advanced imaging software. It was confirmed that patients treated based on the extended time indication also had a good prognosis.
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Affiliation(s)
- Taedong Ok
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Pyeong Ho Yoon
- Department of Radiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Gyu Sik Kim
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Kwon-Duk Seo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
- Department of Neurology, Graduate School of Medicine, Kangwon National University, Chuncheon, Korea.
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Acute stroke care in France: Survey in the 138 stroke units. Rev Neurol (Paris) 2022; 178:1072-1078. [PMID: 36336492 DOI: 10.1016/j.neurol.2022.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND According to the French regulation, stroke units (SU) include both an intensive (I-SU) and a non-intensive (NI-SU) component. Their standard operating procedures have been detailed in governmental directives in 2003 and 2007. OBJECTIVES To evaluate (i) resources available in French SU, (ii) differences between regions, and between France and the 2 close European countries of similar size, and (iii) to identify avenues for improvement. METHODS We performed a survey of all French SU, with an online questionnaire, to evaluate available resources and activity. We compared the 17 French regions, and France, with Germany and Italy. We used 2019 as year of reference. RESULTS The 138 French SU, shared 911 I-SU beds; 123 SU (89.1%) answered the questionnaire. The number of I-SU beds per million inhabitants was 13.6 for the whole country, with important differences between regions, ranging from 7.0 (Reunion Island) to 20.9 (Occitanie region). Per million inhabitants, France had fewer I-SU beds than Germany and Italy (13.5 vs. 29.9 and 23.2 respectively), and fewer thrombectomy centres (0.6 vs. 1.8 and 1.0). Per million inhabitants, France had also lower thrombolysis (203 vs. 402) and thrombectomy (104 vs. 194) rates than Germany, but, compared with Italy, similar thrombolysis rates (203 vs. 202) and higher thrombectomy rates (104 vs. 81). CONCLUSION There are still avenues for improvement in acute stroke care in France, especially concerning the number and regional repartition of I-SU beds, and access to reperfusion therapies.
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Leys D, Chollet F, Bousser MG, Mas J. Rapport 22-11. Prise en charge en urgence dans les unités neurovasculaires des personnes ayant un accident vasculaire cérébral. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2022. [DOI: 10.1016/j.banm.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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15
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Gdovinová Z, Vitková M, Baráková A, Cvopová A. Did the severity of the COVID-19 outbreak affect the quality of acute stroke care? (Data from across the country). Eur Stroke J 2022; 7:175-179. [PMID: 35647318 PMCID: PMC9134781 DOI: 10.1177/23969873221089426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/05/2022] [Indexed: 09/17/2023] Open
Abstract
Introduction The aim of our study was to determine whether the severity of the COVID-19 pandemic affected the quality of acute care of stroke. Methods Data from the stroke register at the National Health Information Centre were analysed. Clinical data from two time periods (the first wave: March-April 2020; the second wave: October-November 2020) were compared using an independent sample t-test and the Wilcoxon-Mann-Whitney two sample rank-sum test. Results The total number of patients admitted with stroke during the second wave of COVID-19 was 1848, versus 1698 in the first wave. The proportion of patients treated by IVT was similar in both waves (275 (20.7%) vs 333 (22.1%), p = 1, difference in location: -0,0003, 95% CI: -5.0 to 5.95). We found no difference in time from the onset of symptoms to treatment (median = 130 min in both waves, p = 0.52, difference in location: 3.99, 95% CI: -6.0 to 14.0), nor in the door-to-needle time (median = 29 vs 30 min, p = 0.08, difference in location: -2.99, 95% CI: -5.0 to 0.008) between the first and the second waves of the pandemic. We found no difference in NIHSS (median = 3 vs 4, p = 0.51, difference in location: 0.00007, 95% CI: -0.9 to 0.000006) and mRS (median = 3 in both waves, p = 0.60, difference in location: -0.00004, 95% CI: -0.00004 to 0.00003) at discharge from hospital between the two periods. Conclusion The severity of the COVID-19 outbreak did not affect the quality of acute stroke care in Slovakia.
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Affiliation(s)
- Zuzana Gdovinová
- Department of Neurology, Faculty of
Medicine, P.J. Safarik University and University Hospital L. Pasteur, Košice,
Slovakia
| | - Marianna Vitková
- Department of Neurology, Faculty of
Medicine, P.J. Safarik University and University Hospital L. Pasteur, Košice,
Slovakia
| | - Anna Baráková
- National Health Information Centre,
Bratislava, Slovakia
| | - Alena Cvopová
- National Health Information Centre,
Bratislava, Slovakia
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16
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Ye Q, Zhai F, Chao B, Cao L, Xu Y, Zhang P, Han H, Wang L, Xu B, Chen W, Wen C, Wang S, Wang R, Zhang L, Jiao L, Liu S, Zhu YC, Wang LD. Rates of intravenous thrombolysis and endovascular therapy for acute ischaemic stroke in China between 2019 and 2020. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 21:100406. [PMID: 35243459 PMCID: PMC8873940 DOI: 10.1016/j.lanwpc.2022.100406] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND In recent years, a series of initiatives have been launched to promote intravenous thrombolysis (IVT) and endovascular therapy (EVT) for acute ischaemic stroke (AIS) in China. We aimed to update the rates of IVT and EVT in China between 2019 and 2020 and to evaluate the current IVT and EVT according to hospital grades. METHODS Cross-sectional data on patients receiving IVT/EVT were derived from the Bigdata Observatory platform for Stroke of China (BOSC). The monthly number of discharged patients with a principal diagnosis of AIS was derived from the first pages of medical records of each hospital. The rates and information of IVT and EVT were analysed according to hospital grades. FINDINGS During this period, 938 tertiary hospitals and 786 secondary hospitals from 31 provinces continuously reported data to the BOSC. The overall IVT rate for AIS was 5·64%, and the EVT rate was 1·45%. The IVT rate in secondary hospitals was higher than that in tertiary hospitals (6·39% vs. 5·39%, P < 0·001), whereas the EVT rate in secondary hospitals was much lower than that in tertiary hospitals (0·29% vs. 1·84%, P < 0·001). Significant differences in demographic and clinical characteristics of patients receiving IVT/EVT were also shown between tertiary and secondary hospitals. INTERPRETATION The rates of IVT and EVT for AIS have greatly increased in China, but there is still a large gap compared with developed countries. Hospital inhomogeneity in IVT and EVT suggests the importance of developing a region-specific network for stroke treatment. FUNDING None.
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Affiliation(s)
- Qing Ye
- Department of Neurology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
- The General Office of Stroke Prevention Project Committee, National Health Commission of the People's Republic of China, Beijing, China
| | - Feifei Zhai
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Baohua Chao
- The General Office of Stroke Prevention Project Committee, National Health Commission of the People's Republic of China, Beijing, China
| | - Lei Cao
- The General Office of Stroke Prevention Project Committee, National Health Commission of the People's Republic of China, Beijing, China
| | - Yun Xu
- Department of Neurology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Peilan Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Hongxing Han
- Department of Neurology, Linyi People's Hospital, Shandong, China
| | - Lihua Wang
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Bing Xu
- Department of Neurology and Neuroscience, Shenyang First People's Hospital, Liaoning, China
| | - Wenhuo Chen
- Department of Neurointervention, Zhangzhou affiliated Hospital of Fujian Medical University, Fujian, China
| | - Changming Wen
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Shouchun Wang
- Department of Neurology, The First Hospital of Jilin University, Jilin, China
| | - Runqing Wang
- Department of Neurology, Zhengzhou Central Hospital, Zhengzhou, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Shandong, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yi-Cheng Zhu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Long-De Wang
- The General Office of Stroke Prevention Project Committee, National Health Commission of the People's Republic of China, Beijing, China
- School of Public Health, Peking University, Beijing, China
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17
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Patient Pathways During Acute in-Hospital Stroke Treatment: A Qualitative Multi-Method Study. Int J Integr Care 2022; 22:16. [PMID: 35291205 PMCID: PMC8877851 DOI: 10.5334/ijic.5657] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/28/2022] [Indexed: 11/20/2022] Open
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18
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Schaller-Paule MA, Foerch C, Bohmann FO, Lapa S, Misselwitz B, Kohlhase K, Rosenow F, Strzelczyk A, Willems LM. Predicting Poststroke Pneumonia in Patients With Anterior Large Vessel Occlusion: A Prospective, Population-Based Stroke Registry Analysis. Front Neurol 2022; 13:824450. [PMID: 35250827 PMCID: PMC8893016 DOI: 10.3389/fneur.2022.824450] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/24/2022] [Indexed: 11/15/2022] Open
Abstract
Objective To assess predictive factors for poststroke pneumonia (PSP) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) of the anterior circulation, with special regard to the impact of intravenous thrombolysis (IVT) and endovascular treatment (EVT) on the risk of PSP. As a secondary goal, the validity of the A2DS2, PNEUMONIA, and ISAN scores in LVO will be determined. Methods Analysis was based on consecutive data for the years 2017 to 2019 from the prospective inpatient stroke registry covering the entire federal state of Hesse, Germany, using the Kruskal-Wallis test and binary logistic regression. Results Data from 4,281 patients with LVO were included in the analysis (54.8% female, median age = 78 years, range = 18–102), of whom 66.4% (n = 2,843) received recanalization therapy (RCT). In total, 19.4% (n = 832) of all LVO patients developed PSP. Development of PSP was associated with an increase in overall in-hospital mortality of 32.1% compared with LVO patients without PSP (16.4%; p < 0.001). Incidence of PSP was increased in 2132 patients with either EVT (n = 928; 25.9% PSP incidence) or combined EVT plus IVT (n = 1,204; 24.1%), compared with 2,149 patients with IVT alone (n = 711; 15.2%) or conservative treatment only (n = 1,438; 13.5%; p < 0.001). Multivariate analysis identified EVT (OR 1.5) and combined EVT plus IVT (OR 1.5) as significant independent risk factors for PSP. Furthermore, male sex (OR 1.9), age ≥ 65 years (OR 1.7), dysphagia (OR 3.2) as well as impaired consciousness at arrival (OR 1.7) and the comorbidities diabetes (OR 1.4) and atrial fibrillation (OR 1.3) were significantly associated risk factors (each p < 0.001). Minor stroke (NIHSS ≤ 4) was associated with a significant lower risk of PSP (OR 0.5). Performance of risk stratification scores varied between A2DS2 (96.1% sensitivity, 20.7% specificity), PNEUMONIA (78.2% sensitivity and 45.1% specificity) and ISAN score (98.0% sensitivity, 20.0% specificity). Conclusion Nearly one in five stroke patients with LVO develops PSP during acute care. This risk of PSP is further increased if an EVT is performed. Other predictive factors are consistent with those previously described for all AIS patients. Available risk stratification scores proved to be sensitive tools in LVO patients but lack specificity.
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Affiliation(s)
- Martin A. Schaller-Paule
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
- *Correspondence: Martin A. Schaller-Paule
| | - Christian Foerch
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Ferdinand O. Bohmann
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Sriramya Lapa
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | | | - Konstantin Kohlhase
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Felix Rosenow
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
- Epilepsy Center Frankfurt Rhine-Main, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
- Epilepsy Center Frankfurt Rhine-Main, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Laurent M. Willems
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
- Epilepsy Center Frankfurt Rhine-Main, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
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Tani T, Imai S, Fushimi K. Impact of the COVID-19 pandemic on emergency admission for patients with stroke: a time series study in Japan. Neurol Res Pract 2021; 3:64. [PMID: 34895353 PMCID: PMC8666267 DOI: 10.1186/s42466-021-00163-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Appropriate treatment of stroke immediately after its onset contributes to the improved chances, while delay in hospitalisation affects stroke severity and fatality. This study aimed to determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on emergency hospitalisation of patients with stroke in Japan. METHODS This was an observational study that used nationwide administrative data of hospitalised patients diagnosed with stroke. We cross-sectionally observed patients' background factors during April and May 2020, when the COVID-19 pandemic-related state of emergency was declared; we also observed these factors in the same period in 2019. We also modelled monthly trends in emergency stroke admissions, stroke admissions at each level of the Japan Coma Scale (JCS), fatalities within 24 h, stroke care unit use, intravenous thrombolysis administration, and mechanical thrombectomy implementation using interrupted time series (ITS) regression. RESULTS There was no difference in patients' pre-hospital baseline characteristics between the pre-pandemic and pandemic periods. However, ITS regression revealed a significant change in the number of emergency stroke admissions after the beginning of the pandemic (slope: risk ratio [RR] = 0.97, 95% confidence interval [CI]: 0.95-0.99, P = 0.027). There was a significant difference in the JCS score for impaired consciousness in emergency stroke, which was more severe during the pandemic than the pre-pandemic (JCS3 in level: RR = 1.75, 95% CI: 1.29-2.33, P < 0.001). There was no change in the total number of fatalities with COVID-19, compared with those without COVID-19, but there were significantly more fatalities within 24 h of admission (fatalities within 24 h: RR = 1.75, 95% CI: 1.29-2.33, P < 0.001). CONCLUSIONS The infection prevalence of COVID-19 increased the number of fatalities within 24 h as well as the severity of illness in Japan. However, there was no difference in baseline characteristics, intravenous thrombolysis administration, and mechanical thrombectomy implementation during the COVID-19 pandemic. A decrease in the number of patients and fatalities was observed from the time the state of emergency was declared until August, the period of this study.
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Affiliation(s)
- Takuaki Tani
- Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan. .,Clinical Research Center National Hospital Organization, 2-21 Higashigaoka, Meguro-ku, Tokyo, 152-8621, Japan.
| | - Shinobu Imai
- Clinical Research Center National Hospital Organization, 2-21 Higashigaoka, Meguro-ku, Tokyo, 152-8621, Japan.,Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachiozi-shi, Tokyo, 192-0392, Japan
| | - Kiyohide Fushimi
- Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.,Clinical Research Center National Hospital Organization, 2-21 Higashigaoka, Meguro-ku, Tokyo, 152-8621, Japan
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20
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Richter D, Eyding J, Weber R, Bartig D, Grau A, Hacke W, Krogias C. A full year of the COVID-19 pandemic with two infection waves and its impact on ischemic stroke patient care in Germany. Eur J Neurol 2021; 29:105-113. [PMID: 34370900 PMCID: PMC8444778 DOI: 10.1111/ene.15057] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 12/14/2022]
Abstract
Background and purpose Many countries worldwide, including Germany, reported that the first wave of the coronavirus disease 2019 (COVID‐19) pandemic in early 2020 influenced the care of acute ischemic stroke (AIS) patients, but data are lacking for further pandemic wave periods. Methods We conducted a nationwide, retrospective, cross‐sectional study of all hospitalized patients with the main diagnosis of AIS in 2019 and 2020. Primary outcomes were the number of hospitalizations for AIS, the application of stroke unit care, intravenous thrombolysis (IVT), and mechanical thrombectomy (MT), as well as the in‐hospital mortality during the different pandemic periods in 2020 compared to the corresponding periods in 2019. Secondarily, we analyzed differences in outcomes between patients with and without concurrent COVID‐19. Results We included 429,841 cases with AIS, of which 1268 had concurrent COVID‐19. Hospitalizations for AIS declined during both pandemic wave periods in 2020 (first wave: −10.9%, second wave: −4.6%). MT rates were consistently higher throughout 2020 compared to 2019, whereas the IVT rate dropped during the second wave period (16.0% vs. 17.0%, p < 0.001). AIS patients with concurrent COVID‐19 frequently received recanalization treatments, with an overall MT rate of 8.4% and IVT rate of 15.9%. The in‐hospital mortality was high (22.8% vs. 7.5% in noninfected AIS patients, p < 0.001). Conclusions These findings demonstrate a smaller decline in hospitalizations for AIS in the more severe second wave of the COVID‐19 pandemic. AIS patients with and without concurrent COVID‐19 who did seek acute care continued to receive recanalization treatments in Germany.
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Affiliation(s)
- Daniel Richter
- Department of Neurology, St. Josef Hospital Bochum, Ruhr University Bochum, Bochum, Germany
| | - Jens Eyding
- Medical Faculty, Ruhr University Bochum, Bochum, Germany.,Department of Neurology, Community Hospital Herdecke, Herdecke, Germany
| | - Ralph Weber
- Medical Faculty, Ruhr University Bochum, Bochum, Germany.,Department of Neurology, Alfried Krupp Hospital Essen, Essen, Germany
| | - Dirk Bartig
- Department of Neurology, St. Josef Hospital Bochum, Ruhr University Bochum, Bochum, Germany
| | - Armin Grau
- Department of Neurology, Hospital of the City Ludwigshafen, Ludwigshafen, Germany
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Christos Krogias
- Department of Neurology, St. Josef Hospital Bochum, Ruhr University Bochum, Bochum, Germany.,Medical Faculty, Ruhr University Bochum, Bochum, Germany
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21
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Weber R, Bartig D, Krogias C, Richter D, Hacke W, Eyding J. Letter to the Editor: Analysis of stroke patient migration for mechanical thrombectomy and changes in neurointerventional center size in Germany. Neurol Res Pract 2021; 3:32. [PMID: 34092263 PMCID: PMC8182903 DOI: 10.1186/s42466-021-00131-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/19/2021] [Indexed: 11/10/2022] Open
Abstract
AIM AND METHODS To analyse nationwide changes in neurointerventional center size of all German hospitals performing mechanical thrombectomy (MT) in stroke patients from 2016 to 2019. Furthermore, we assessed cross-district patient migration for MT for the first time using hospitals' structured quality reports and German Diagnosis-Related Groups data in 2019. FINDINGS Number of hospitals performing more than 100 MT procedures/year doubled in Germany from 2016 (n = 36) to 2019 (n = 71), and these neurointerventional centers performed 71% of all MT procedures in 2019. The overall increase in MT procedures was largely driven by these high-volume neurointerventional centers with ability to perform MT 24/7 (121% increase as compared with 8% increase in hospitals performing less than 100 MT procedures/year). The highest cross-district patient mobility/transfer of stroke patients for MT was observed in districts adjacent to these high-volume neurointerventional centers with existing neurovascular networks. CONCLUSION The substantial increase in MT procedures observed in Germany between 2016 and 2019 was almost exclusively delivered by high-volume stroke centers performing more than 100 MT procedures per year in established neurovascular networks. As there is still a reasonable number of districts with low MT rates, further structural improvement including implementation of new or expansion of existing neurovascular networks and regional tailored MT triage concepts is needed.
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Affiliation(s)
- Ralph Weber
- Department of Neurology, Alfried Krupp Krankenhaus Essen, Alfried-Krupp-Str. 21, 45131, Essen, Germany.
- Medical Faculty, Ruhr University Bochum, Bochum, Germany.
- Northwest-German Stroke Circle e.V, Bochum, Germany.
| | - Dirk Bartig
- Northwest-German Stroke Circle e.V, Bochum, Germany
- drg market, Osnabrück, Germany
| | - Christos Krogias
- Medical Faculty, Ruhr University Bochum, Bochum, Germany
- Northwest-German Stroke Circle e.V, Bochum, Germany
- Department of Neurology, University Hospital St. Josef-Hospital Bochum, Bochum, Germany
| | - Daniel Richter
- Department of Neurology, University Hospital St. Josef-Hospital Bochum, Bochum, Germany
| | | | - Jens Eyding
- Medical Faculty, Ruhr University Bochum, Bochum, Germany
- Northwest-German Stroke Circle e.V, Bochum, Germany
- Department of Neurology, Gemeinschaftskrankenhaus Herdecke, Herdecke, Germany
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