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Maraziti G, Mosconi MG, Paciaroni M. Comparative study of venous thromboembolic prophylaxis strategies in hemorrhagic stroke: A systematic review and network meta-analysis. Int J Stroke 2024:17474930241248542. [PMID: 38591740 DOI: 10.1177/17474930241248542] [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: 04/10/2024]
Abstract
BACKGROUND Venous thromboembolic events, including deep vein thrombosis (DVT) and pulmonary embolism (PE), are frequent complications in patients with intracerebral hemorrhage (ICH). Various prophylactic strategies have been employed to mitigate this risk, such as heparin, intermittent pneumatic compression (IPC), and graduated compression stockings (GCS). The optimal thromboembolic prophylaxis approach remains uncertain due to the lack of randomized controlled trials (RCTs) comparing all interventions. AIMS We conducted a network meta-analysis and meta-analysis to systematically review and synthesize evidence from RCTs and non-randomized studies on the efficacy and safety of thromboembolic prophylaxis strategies in hospitalized ICH patients. SUMMARY OF FINDINGS Our study followed a registered protocol (PROSPERO CRD42023489217) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines incorporating the extension for network meta-analyses. Search for eligible studies was performed up to December 2023. We considered the occurrence of DVT, PE, hematoma expansion (HE), and all-cause mortality as outcome measures. A total of 16 studies, including 7 RCTs and 9 non-randomized studies, were included in the analysis. Network meta-analysis revealed that IPC demonstrated the highest efficacy in reducing DVT incidence (odds ratios (OR) 0.30, 95% confidence interval (CI) 0.08-1.16), particularly considering only RCTs (OR 0.33, 95% CI 0.16-0.67). GCS showed the highest safety profile for HE (OR 0.67, 95% CI 0.14-3.13), but without efficacy. Chemoprophylaxis did not reduce the risk of PE events (OR 1.10, 95% CI 0.17-7.19) with a higher occurrence of HE (OR 1.33, 95% CI 0.60-2.96), but the differences were not significant. CONCLUSION Our study supports the use of IPC as the primary thromboembolic prophylaxis measure in ICH patients. Further research, including head-to-head RCTs, is needed to strengthen the evidence base and optimize clinical decision-making for thromboembolic prophylaxis in this vulnerable patient population.
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Affiliation(s)
- Giorgio Maraziti
- Internal Cardiovascular and Emergency Medicine-Stroke Unit, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Maria Giulia Mosconi
- Internal Cardiovascular and Emergency Medicine-Stroke Unit, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Maurizio Paciaroni
- Internal Cardiovascular and Emergency Medicine-Stroke Unit, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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Zhang Z, Cai H, Vleggeert-Lankamp CLA. Thromboembolic prophylaxis in neurosurgical practice: a systematic review. Acta Neurochir (Wien) 2023; 165:3119-3135. [PMID: 37796296 PMCID: PMC10624710 DOI: 10.1007/s00701-023-05792-3] [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: 06/21/2023] [Accepted: 09/01/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND In neurosurgical patients, the risk of developing venous thromboembolism (VTE) is high due to the relatively long duration of surgical interventions, usually long immobilization time after surgery, and possible neurological deficits which can negatively influence mobility. In neurosurgical clinical practice, there is lack of consensus on optimal prophylaxis against VTE, mechanical or pharmacological. OBJECTIVE To systematically review available literature on the incidence of VTE in neurosurgical interventions and to establish an optimum prevention strategy. METHODS A literature search was performed in PubMed, Embase, Web of Science, Cochrane Library, and EmCare, based on a sensitive search string combination. Studies were selected by predefined selection criteria, and risk of bias was assessed by Newcastle-Ottawa Quality Assessment Scale and Cochrane risk of bias. RESULTS Twenty-five studies were included, half of which had low risk of bias (21 case series, 3 comparative studies, 1 RCT). VTE was substantially higher if the evaluation was done by duplex ultrasound (DUS), or another systematic screening method, in comparison to clinical evaluation (clin). Without prophylaxis DVT, incidence varied from 4 (clin) to 10% (DUS), studies providing low molecular weight heparin (LMWH) reported an incidence of 2 (clin) to 31% (DUS), providing LMWH and compression stockings (CS) reported an incidence of 6.4% (clin) to 29.8% (DUS), and providing LMWH and intermittent pneumatic compression devices (IPC) reported an incidence of 3 (clin) to 22.3% (DUS). Due to a lack of data, VTE incidence could not meaningfully be compared between patients with intracranial and spine surgery. The reported incidence of pulmonary embolism (PE) was 0 to 7.9%. CONCLUSION Low molecular weight heparin, compression stockings, and intermittent pneumatic compression devices were all evaluated to give reduction in VTE, but data were too widely varying to establish an optimum prevention strategy. Systematic screening for DVT reveals much higher incidence percentages in comparison to screening solely on clinical grounds and is recommended in follow-up of neurosurgical procedures with an increased risk for DVT development in order to prevent occurrence of PE.
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Affiliation(s)
- Zhaoyuan Zhang
- Department of Neurosurgery, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Husule Cai
- Department of Neurosurgery, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Carmen L A Vleggeert-Lankamp
- Department of Neurosurgery, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
- Spaarne Hospital, Hoofddorp, Haarlem, The Netherlands
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3
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Ji R, Wang L, Liu X, Liu Y, Wang D, Wang W, Zhang R, Jiang R, Jia J, Feng H, Ding Z, Ju Y, Lu J, Liu G, Wang Y, Zhao X. A novel risk score to predict deep vein thrombosis after spontaneous intracerebral hemorrhage. Front Neurol 2022; 13:930500. [PMID: 36388194 PMCID: PMC9650187 DOI: 10.3389/fneur.2022.930500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/14/2022] [Indexed: 12/03/2022] Open
Abstract
Background and purpose Studies showed that patients with hemorrhagic stroke are at a higher risk of developing deep vein thrombosis (DVT) than those with ischemic stroke. We aimed to develop a risk score (intracerebral hemorrhage-associated deep vein thrombosis score, ICH-DVT) for predicting in-hospital DVT after ICH. Methods The ICH-DVT was developed based on the Beijing Registration of Intracerebral Hemorrhage, in which eligible patients were randomly divided into derivation (60%) and internal validation cohorts (40%). External validation was performed using the iMCAS study (In-hospital Medical Complication after Acute Stroke). Independent predictors of in-hospital DVT after ICH were obtained using multivariable logistic regression, and β-coefficients were used to generate a scoring system of the ICH-DVT. The area under the receiver operating characteristic curve (AUROC) and the Hosmer–Lemeshow goodness-of-fit test were used to assess model discrimination and calibration, respectively. Results The overall in-hospital DVT after ICH was 6.3%, 6.0%, and 5.7% in the derivation (n = 1,309), internal validation (n = 655), and external validation (n = 314) cohorts, respectively. A 31-point ICH-DVT was developed from the set of independent predictors including age, hematoma volume, subarachnoid extension, pneumonia, gastrointestinal bleeding, and length of hospitalization. The ICH-DVT showed good discrimination (AUROC) in the derivation (0.81; 95%CI = 0.79–0.83), internal validation (0.83, 95%CI = 0.80–0.86), and external validation (0.88; 95%CI = 0.84–0.92) cohorts. The ICH-DVT was well calibrated (Hosmer–Lemeshow test) in the derivation (P = 0.53), internal validation (P = 0.38), and external validation (P = 0.06) cohorts. Conclusion The ICH-DVT is a valid grading scale for predicting in-hospital DVT after ICH. Further studies on the effect of the ICH-DVT on clinical outcomes after ICH are warranted.
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Affiliation(s)
- Ruijun Ji
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Beijing Key Laboratory of Brain Function Reconstruction, Beijing, China
| | - Linlin Wang
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinyu Liu
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yanfang Liu
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Dandan Wang
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wenjuan Wang
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Runhua Zhang
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ruixuan Jiang
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jiaokun Jia
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Feng
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zeyu Ding
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yi Ju
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jingjing Lu
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Gaifen Liu
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Beijing Key Laboratory of Brain Function Reconstruction, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Beijing Key Laboratory of Brain Function Reconstruction, Beijing, China
- *Correspondence: Xingquan Zhao
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Tøndel BG, Morelli VM, Hansen J, Brækkan SK. Risk factors and predictors for venous thromboembolism in people with ischemic stroke: A systematic review. J Thromb Haemost 2022; 20:2173-2186. [PMID: 35815351 PMCID: PMC9796787 DOI: 10.1111/jth.15813] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/15/2022] [Accepted: 07/01/2022] [Indexed: 01/07/2023]
Abstract
Identification of individuals with ischemic stroke at particularly high risk of venous thromboembolism (VTE) is crucial for targeted thromboprophylaxis. To guide clinical decision-making and development of risk prediction models, increased knowledge on risk factors and biomarkers is needed. Therefore, we set out to identify risk factors and predictors for VTE in people with ischemic stroke by conducting a systematic review of the literature. Medline and Embase were searched from January 1990 and onwards. Studies investigating demographic, clinical, and/or laboratory factors for stroke-related VTE were considered. Two reviewers screened all retrieved records, independently and in duplicate. Risk of bias assessments were guided by a structured framework (PROSPERO-ID: CRD42020176361). Of 4674 identified records, 26 studies were included. Twenty-six demographic, clinical, and laboratory factors associated with increased risk of stroke-related VTE after multivariable adjustments were identified. The following factors were reported by ≥2 studies: prior VTE, cancer, prestroke disability, leg weakness, increasing lesion volume of the brain infarct, infection, low Barthel Index, increasing length of hospital stay, biochemical indices of dehydration, as well as elevated levels of D-dimer, C-reactive protein, and homocysteine. The majority of the studies were of poor quality with moderate or high risk of bias. In conclusion, this systematic review informs on several potential risk factors and predictors for VTE in people with ischemic stroke. To improve risk stratification and guide development of risk prediction models, further confirmation is needed because there were few high-quality studies on each factor.
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Affiliation(s)
- Birgitte G. Tøndel
- Thrombosis Research Center (TREC), Department of Clinical MedicineUiT – the Arctic University of NorwayTromsøNorway
| | - Vânia M. Morelli
- Thrombosis Research Center (TREC), Department of Clinical MedicineUiT – the Arctic University of NorwayTromsøNorway
- Division of Internal MedicineUniversity Hospital of North NorwayTromsøNorway
| | - John‐Bjarne Hansen
- Thrombosis Research Center (TREC), Department of Clinical MedicineUiT – the Arctic University of NorwayTromsøNorway
- Division of Internal MedicineUniversity Hospital of North NorwayTromsøNorway
| | - Sigrid K. Brækkan
- Thrombosis Research Center (TREC), Department of Clinical MedicineUiT – the Arctic University of NorwayTromsøNorway
- Division of Internal MedicineUniversity Hospital of North NorwayTromsøNorway
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Li L, Murthy SB. Cardiovascular Events After Intracerebral Hemorrhage. Stroke 2022; 53:2131-2141. [DOI: 10.1161/strokeaha.122.036884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiovascular events after primary intracerebral hemorrhage (ICH) have emerged as a leading cause of poor functional outcomes and mortality during the long-term recovery after an ICH. These events encompass arterial ischemic events such as ischemic stroke and myocardial infarction, arterial hemorrhagic events that include recurrent ICH, and venous thrombotic events such as venous thromboembolism. The purpose of this review is to summarize the cardiovascular complications after ICH, epidemiology and associated risk factors, and their impact on ICH outcomes. Additionally, we will highlight possible pathophysiological mechanisms to explain the short- and long-term increased risks of ischemic and hemorrhagic events after ICH. Finally, we will highlight potential secondary stroke and venous thrombotic prevention strategies often not considered after ICH, balanced against the risk of ICH recurrence.
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Affiliation(s)
- Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (L.L.)
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, NY (S.B.M.)
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Cui P, McCullough LD, Hao J. Brain to periphery in acute ischemic stroke: Mechanisms and clinical significance. Front Neuroendocrinol 2021; 63:100932. [PMID: 34273406 PMCID: PMC9850260 DOI: 10.1016/j.yfrne.2021.100932] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/27/2021] [Accepted: 07/12/2021] [Indexed: 01/21/2023]
Abstract
The social and public health burdens of ischemic stroke have been increasing worldwide. In addition to focal brain damage, acute ischemic stroke (AIS) provokes systemic abnormalities across peripheral organs. AIS profoundly alters the autonomic nervous system, hypothalamic-pituitary-adrenal axis, and immune system, which further yield deleterious organ-specific consequences. Poststroke systemic pathological alterations in turn considerably contribute to the progression of ischemic brain injury, which accounts for the substantial impact of systemic complications on stroke outcomes. This review provides a comprehensive and updated pathophysiological model elucidating the systemic effects of AIS. To address their clinical significance and inform stroke management, we also outline the resulting systemic complications at particular stages of AIS and highlight the mechanisms. Future therapeutic strategies should attempt to integrate the treatment of primary brain lesions with interventions for secondary systemic complications, and should be tailored to patient individualized characteristics to optimize stroke outcomes.
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Affiliation(s)
- Pan Cui
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Louise D McCullough
- Department of Neurology, University of Texas Health Science Centre, Houston, TX 77030, USA
| | - Junwei Hao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.
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7
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Melmed KR, Boehme A, Ironside N, Murthy S, Park S, Agarwal S, Connolly ES, Claassen J, Elkind MSV, Roh D. Respiratory and Blood Stream Infections are Associated with Subsequent Venous Thromboembolism After Primary Intracerebral Hemorrhage. Neurocrit Care 2020; 34:85-91. [PMID: 32385835 PMCID: PMC7223996 DOI: 10.1007/s12028-020-00974-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Infection and venous thromboembolism (VTE) are associated with worse outcomes after intracerebral hemorrhage (ICH). The relationship between infection and VTE in ICH patients is unclear. We hypothesized that infection would be associated with subsequent VTE after ICH. METHODS We retrospectively studied consecutively admitted spontaneous primary ICH patients from 2009 to 2018 surviving beyond 24 h. The primary predictor variable was infection, diagnosed prior to VTE. The primary outcome was VTE. We used multivariable logistic regression models to estimate the odds ratios and 95% confidence intervals (OR, 95% CI) for VTE risk after infection of any type, after adjusting for ICH score, length of stay and days to deep venous thrombosis (DVT) prophylaxis. Similar analysis was done to estimate the association of infection subtypes, including respiratory and urinary and blood stream infections (BSI) with VTE. RESULTS There were 414 patients (mean age 65 years, 47% female) that met were analyzed. Infection was diagnosed in 181 (44%) patients. Incident VTE was diagnosed in 36 (9%) patients, largely comprised of DVT (n = 32; 89%). Infection overall was associated with increased risk of subsequent VTE (adjusted OR 4.5, 95% CI 1.6-12.6). Respiratory (adjusted OR 5.7, 95% CI 2.8-11.7) and BSI (adjusted OR 4.0, 95% CI 1.3-11.0) were associated with future VTE. Urinary and other infections were not associated with subsequent VTE. CONCLUSIONS Infections are associated with subsequent risk of VTE among patients with ICH. Further investigation is required to elucidate mechanisms behind this association and to improve VTE prevention after ICH.
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Affiliation(s)
- Kara R Melmed
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA.
- Department of Neurology, NYU Langone Health, New York, NY, USA.
| | - Amelia Boehme
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Natasha Ironside
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Santosh Murthy
- Department of Neurology, Weill Cornell Medical Center, New York, NY, USA
| | - Soojin Park
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - E Sander Connolly
- Department of Neurosurgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - David Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Downregulation of miR-103a-3p Contributes to Endothelial Progenitor Cell Dysfunction in Deep Vein Thrombosis Through PTEN Targeting. Ann Vasc Surg 2020; 64:339-346. [DOI: 10.1016/j.avsg.2019.10.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/03/2019] [Accepted: 10/12/2019] [Indexed: 01/04/2023]
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El-Khawas K, Lloyd-Donald P, Hart GK, Gonzalvo A, Smith C, Eastwood GM, Bellomo R. Prospective Longitudinal Evaluation of Coagulation with Novel Thromboelastography Technology in Patients After Subarachnoid Hemorrhage: A Pilot Study. World Neurosurg 2019; 136:e181-e195. [PMID: 31887461 DOI: 10.1016/j.wneu.2019.12.109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is limited knowledge of whether hypercoagulability is present after subarachnoid hemorrhage (SAH) or about its timing of onset, duration, and severity. To conduct a pilot new-generation thromboelastography (TEG) technology (TEG6s)-based and conventional coagulation test-supported longitudinal assessment of coagulation in patients with SAH. METHODS We prospectively enrolled patients with nontraumatic SAH on admission from May 2015 to May 2016. We performed TEG6s measurements and conventional coagulation tests on days 1, 2, 3, 5, 7, 10, and 14 and compared them with TEG6s parameters in healthy volunteers. RESULTS We studied 14 patients and 72 TEG6s measurements. Of these patients, 10 (71.4%) were admitted to the intensive care unit. Mean age was 57.5 (±14.5) years, Acute Physiology and Chronic Health Evaluation III score 58.2 (±26.6), length of hospital stay was 23 (±11.7) days, and mortality was 14.3%. At baseline, conventional coagulation tests were within normal range. However, TEG6s parameters already showed increased coagulability. Thereafter, alpha angle, reaction time, functional fibrinogen level, and maximum amplitude rapidly and significantly increased (P < 0.01) compared with healthy controls. Ten (71.4%) patients demonstrated a >20% increase in coagulability based on TEG6s parameters from their baseline. Moreover, TEG6s hypercoagulability peaked at day 10 and only showed an initial partial decline towards normal by day 14. Similarly, platelet counts and fibrinogen levels increased over this period (P < 0.01) CONCLUSIONS: Using TEG6s technology, we found significant and progressive hypercoagulability in 70% of patients, with an early dominant contribution from hyperfibrinogenemia and increased fibrin formation and partial contribution from thrombocytosis, beginning on the first day, increasing to peak values by day 10, and then partly declining toward normal by day 14.
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Affiliation(s)
- Khaled El-Khawas
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, Australia.
| | | | - Graeme K Hart
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Health and BioMedical Informatics Centre, The University of Melbourne, Melbourne, Australia
| | - Augusto Gonzalvo
- Department of Neurosurgery, Austin Hospital, Melbourne, Australia
| | - Carole Smith
- Department of Haematology, Austin Hospital, Melbourne, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Australia
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10
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Kim WJ, Bae S, Kang CJ, Kim DY. Clinical Factors Associated with Deep Vein Thrombosis in Rehabilitation Patients Suspected of Thromboembolism after Cerebral Infarction. BRAIN & NEUROREHABILITATION 2019; 13:e7. [PMID: 36744188 PMCID: PMC9879456 DOI: 10.12786/bn.2020.13.e7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 10/25/2019] [Accepted: 10/27/2019] [Indexed: 11/08/2022] Open
Abstract
The aim of this study is to investigate the association between characteristics of cerebral infarction lesion (vascular territory, etiology, and size), functional status and the occurrence of thromboembolism in patients suspected of having thromboembolism in a rehabilitation setting after cerebral infarction. Cerebral infarction patients who were suspected of having thromboembolism and who had undergone deep vein thrombosis (DVT) evaluation were included in analyses. Of the total 916 cerebral infarction patients, 65 patients were suspected of having DVT; 27 patients belonged to the DVT group and 38 patients belonged to the non-DVT group. The DVT (+) group was more likely to have a higher ratio of female, previous DVT history, middle cerebral artery (MCA) infarction, large arterial disease, modified Rankin Scale (mRS) score 5, abnormal speech and higher D-dimer. In multivariate logistic regression analysis, female sex, MCA infarction and mRS score 5 were significantly associated with the occurrence of thromboembolism in patients suspected of having thromboembolism. In contrast, other functional status, cerebral infarction etiology (Trial of ORG 10172 in Acute Stroke Treatment [TOAST] classification), and infarct volume were not associated with the occurrence of thromboembolism. In this study, female gender, MCA infarction, and mRS score 5 could be potential risk factors for thromboembolism in rehabilitation patients after cerebral infarction.
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Affiliation(s)
- Won Jun Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suhwan Bae
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Cheon Ji Kang
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Yul Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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11
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Agarwal P, Abdullah KG, Ramayya AG, Nayak NR, Lucas TH. A Retrospective Propensity Score-Matched Early Thromboembolic Event Analysis of Prothrombin Complex Concentrate vs Fresh Frozen Plasma for Warfarin Reversal Prior to Emergency Neurosurgical Procedures. Neurosurgery 2019; 82:877-886. [PMID: 29106685 DOI: 10.1093/neuros/nyx327] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 05/16/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Reversal of therapeutic anticoagulation prior to emergency neurosurgical procedures is required in the setting of intracranial hemorrhage. Multifactor prothrombin complex concentrate (PCC) promises rapid efficacy but may increase the probability of thrombotic complications compared to fresh frozen plasma (FFP). OBJECTIVE To compare the rate of thrombotic complications in patients treated with PCC or FFP to reverse therapeutic anticoagulation prior to emergency neurosurgical procedures in the setting of intracranial hemorrhage at a level I trauma center. METHODS Sixty-three consecutive patients on warfarin therapy presenting with intracranial hemorrhage who received anticoagulation reversal prior to emergency neurosurgical procedures were retrospectively identified between 2007 and 2016. They were divided into 2 cohorts based on reversal agent, either PCC (n = 28) or FFP (n = 35). The thrombotic complications rates within 72 h of reversal were compared using the χ2 test. A multivariate propensity score matching analysis was used to limit the threat to interval validity from selection bias arising from differences in demographics, laboratory values, history, and clinical status. RESULTS Thrombotic complications were uncommon in this neurosurgical population, occurring in 1.59% (1/63) of treated patients. There was no significant difference in the thrombotic complication rate between groups, 3.57% (1/28; PCC group) vs 0% (0/35; FFP group). Propensity score matching analysis validated this finding after controlling for any selection bias. CONCLUSION In this limited sample, thrombotic complication rates were similar between use of PCC and FFP for anticoagulation reversal in the management of intracranial hemorrhage prior to emergency neurosurgical procedures.
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Affiliation(s)
- Prateek Agarwal
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kalil G Abdullah
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashwin G Ramayya
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nikhil R Nayak
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy H Lucas
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
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Khan MT, Ikram A, Saeed O, Afridi T, Sila CA, Smith MS, Irshad K, Shuaib A. Deep Vein Thrombosis in Acute Stroke - A Systemic Review of the Literature. Cureus 2017; 9:e1982. [PMID: 29503776 PMCID: PMC5825043 DOI: 10.7759/cureus.1982] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 12/23/2017] [Indexed: 12/22/2022] Open
Abstract
We present a systemic review of available literature on the complications of deep venous thrombosis that develops in patients presenting with acute stroke. There are several pharmacological and physical treatment options available and used. We aim to summarize the management plans currently used at different centers. In conclusion, low-dose anticoagulant therapy for ischemic stroke is recommended. In the case of intracerebral hemorrhage, pneumatic sequential compression devices should be placed initially, followed by the administration of ultra-fractioned heparin on the next day, and then oral anticoagulant therapy to replace the heparin after a week in high-risk patients. Similar prophylactic treatment recommendations are used for subarachnoid hemorrhage.
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Affiliation(s)
| | - Asad Ikram
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Omar Saeed
- Department of Neurology, Zeenat Qureshi Stroke Insitute
| | | | - Cathy A Sila
- Department of Neurology, University Hospitals Case Western Reserve University School of Medicine
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13
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Ormseth CH, Sheth KN, Saver JL, Fonarow GC, Schwamm LH. The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke Vasc Neurol 2017; 2:94-105. [PMID: 28959497 PMCID: PMC5600018 DOI: 10.1136/svn-2017-000092] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 04/26/2017] [Indexed: 01/06/2023] Open
Abstract
The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.
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Affiliation(s)
- Cora H Ormseth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeffrey L Saver
- Department of Neurology, UCLA Medical Center, Los Angeles, California, USA
| | - Gregg C Fonarow
- Department of Cardiology, UCLA Medical Center, Los Angeles, California, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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14
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Sisante JFV, Abraham MG, Phadnis MA, Billinger SA, Mittal MK. Ambulatory Status Protects against Venous Thromboembolism in Acute Mild Ischemic Stroke Patients. J Stroke Cerebrovasc Dis 2016; 25:2496-501. [PMID: 27423367 DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 05/18/2016] [Accepted: 06/17/2016] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Ischemic stroke patients are at high risk (up to 18%) for venous thromboembolism. We conducted a retrospective cross-sectional study to understand the predictors of acute postmild ischemic stroke patient's ambulatory status and its relationship with venous thromboembolism, hospital length of stay, and in-hospital mortality. METHODS We identified 522 patients between February 2006 and May 2014 and collected data about patient demographics, admission NIHSS (National Institutes of Health Stroke Scale), venous thromboembolism prophylaxis, ambulatory status, diagnosis of venous thromboembolism, and hospital outcomes (length of stay, mortality). Chi-square test, t-test and Wilcoxon rank-sum test, and binary logistic regression were used for statistical analysis as appropriate. RESULTS A total of 61 (11.7%), 48 (9.2%), and 23 (4.4%) mild ischemic stroke patients developed venous thromboembolism, deep venous thrombosis, and pulmonary embolism, respectively. During hospitalization, 281 (53.8%) patients were ambulatory. Independent predictors of in-hospital ambulation were being married (OR 1.64, 95% CI 1.10-2.49), being nonreligious (OR 2.19, 95% CI 1.34-3.62), admission NIHSS (per unit decrease in NIHSS; OR 1.62, 95% CI 1.39-1.91), and nonuse of mechanical venous thromboembolism prophylaxis (OR 1.62, 95% CI 1.02-2.61). After adjusting for confounders, ambulatory patients had lower rates of venous thromboembolism (OR .47, 95% CI .25-.89), deep venous thrombosis (OR .36, 95% CI .17-.73), prolonged length of hospital stay (OR .24, 95% CI .16-.37), and mortality (OR .43, 95% CI .21-.84). CONCLUSIONS Our findings suggest that for hospitalized acute mild ischemic stroke patients, ambulatory status is an independent predictor of venous thromboembolism (specifically deep venous thrombosis), hospital length of stay, and in-hospital mortality.
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Affiliation(s)
- Jason-Flor V Sisante
- Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, Kansas
| | - Michael G Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas; Department of Radiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Milind A Phadnis
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, Kansas
| | - Sandra A Billinger
- Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, Kansas
| | - Manoj K Mittal
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas.
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15
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Revilla-Pacheco F, Lerma C, Franco-Granillo J, Manrique-Guzman S. Prevalence of Aneurysmal Subarachnoid Hemorrhage Safety Indicators and Their Relation with Health Care Outcomes in a Mexican Population. World Neurosurg 2016; 91:1-5. [DOI: 10.1016/j.wneu.2016.03.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 11/16/2022]
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16
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Prophylactic heparin in acute intracerebral hemorrhage: a propensity score-matched analysis of the INTERACT2 study. Int J Stroke 2016; 11:549-56. [DOI: 10.1177/1747493016641113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 01/17/2016] [Indexed: 11/15/2022]
Abstract
Background Indication and timing of pharmacological venous thromboembolism prophylaxis in intracerebral hemorrhage patients is controversial. Aims To determine whether use of subcutaneous heparin during the first 7 days after spontaneous intracerebral hemorrhage increases risks of death and disability. Methods Data are from the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2) study. Patients with acute intracerebral hemorrhage (<6 hours) and elevated systolic blood pressure were included; patients received subcutaneous heparin following local best practice standards of care. Multivariable logistic regression and propensity score matched analysis were used to determine associations of heparin use on death and disability (modified Rankin scale) at 90 days. Results In 2525 patients with available data, there were 465 (22.5%) who received subcutaneous heparin. They had higher death or major disability at 90 days in crude (odds ratio 2.29, 95% confidence interval 1.85–2.84; p < 0.001), adjusted (odds ratio 1.62, 95% confidence interval 1.26–2.09; p < 0.001) and propensity score matched (odds ratio 2.06, 95% confidence interval 1.53–2.77; p < 0.001) analyses. In propensity score matched analysis, heparin-treated patients had significant lower mortality (odds ratio 0.55, 95% CI 0.35–0.87; p = 0.01) but greater major disability (odds ratio 1.68, 95% confidence interval 1.25–2.28; p < 0.001) at 90 days. However, no mortality difference was found in analysis restricted to 48-hour survivors. Conclusions Use of subcutaneous heparin is associated with poor outcome in acute intracerebral hemorrhage, driven by increased residual disability. Despite the limitations of this study, and no clear relation of heparin with bleeding risk, we recommend careful consideration of the need for venous thromboembolism prophylaxis with heparin in intracerebral hemorrhage patients. Trial registration http://www.clinicaltrials.gov NCT00716079.
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17
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Tang L, Wu YY, Lip GYH, Yin P, Hu Y. Heart failure and risk of venous thromboembolism: a systematic review and meta-analysis. LANCET HAEMATOLOGY 2015; 3:e30-44. [PMID: 26765646 DOI: 10.1016/s2352-3026(15)00228-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 10/20/2015] [Accepted: 10/21/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Venous thromboembolism is a major global health problem that is often secondary to other clinical situations. Many studies have investigated the association between venous thromboembolism and heart failure, but have yielded inconsistent findings. We aimed to quantify the absolute and relative risks (RR) for venous thromboembolism in patients with heart failure after hospital admission. We also assessed rates of venous thromboembolism in patients in different settings. METHODS In this systematic review and meta-analysis, we searched for studies investigating the risk of venous thromboembolism in patients in hospital with heart failure. We searched for studies published between Jan 1, 1955, and March 31, 2015, in PubMed, Embase, Evidence-Based Medicine Reviews, Allied and Complementary Medicine Database, Ovid HealthSTAR, Global Health, Ovid Nursing Database, Web of Science, CINAHL Plus, ProQuest Central, Conference Papers Index, BIOSIS Previews, and ClinicalTrials.gov. All cohort studies and subgroup analyses of randomised controlled trials (RCTs) were eligible for inclusion if they reported venous thromboembolism rates (number of events per follow-up period) or RR estimates. We extracted data from published reports and contacted the corresponding authors of records with insufficient quantitative data. RRs and 95% CIs were pooled using a random-effects model. This study is registered with PROSPERO, number CRD42014015504. FINDINGS Of 8673 records identified, we included 71 studies with data from 88 cohorts in our analysis, with 59 cohorts included in the assessment of venous thromboembolism rates and 46 cohorts included in the meta-analysis of heart failure and risk of venous thromboembolism. Venous thromboembolism rates varied widely in patients in hospital with heart failure from different settings. The overall median symptomatic venous thromboembolism rate was 2·48% (IQR 0·84-5·61); rates was were 3·73% (1·05-7·31) for patients who did not receive thromboprophylaxis and 1·47% (0·64-3·54) for those who did. Overall, patients with heart failure in hospital had an RR of 1·51 (1·36-1·68) for venous thromboembolism. The overall I(2) statistic was 96·1% and there was no evidence of publication bias (Egger's test, p=0·46). INTERPRETATION Heart failure is a common independent risk factor for venous thromboembolism. Thromoboprophylaxis should be considered in clinical practice for high-risk patients. FUNDING National Natural Science Foundation.
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Affiliation(s)
- Liang Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying-Ying Wu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gregory Y H Lip
- Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Ping Yin
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Kaur P, Muthuraman A, Kaur M. The implications of angiotensin-converting enzymes and their modulators in neurodegenerative disorders: current and future perspectives. ACS Chem Neurosci 2015; 6:508-21. [PMID: 25680080 DOI: 10.1021/cn500363g] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Angiotensin converting enzyme (ACE) is a dipeptidyl peptidase transmembrane bound enzyme. Generally, ACE inhibitors are used for the cardiovascular disorders. ACE inhibitors are primary agents for the management of hypertension, so these cannot be avoided for further use. The present Review focuses on the implications of angiotensin converting enzyme inhibitors in neurodegenerative disorders such as dementia, Alzheimer's disease, Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis, stroke, and diabetic neuropathy. ACE inhibitors such as ramipril, captopril, perindopril, quinapril, lisinopril, enalapril, and trandolapril have been documented to ameliorate the above neurodegenerative disorders. Neurodegeneration occurs not only by angiotensin II, but also by other endogenous factors, such as the formation of free radicals, amyloid beta, immune reactions, and activation of calcium dependent enzymes. ACE inhibitors interact with the above cellular mechanisms. Thus, these may act as a promising factor for future medicine for neurological disorders beyond the cardiovascular actions. Central acting ACE inhibitors can be useful in the future for the management of neuropathic pain due to following actions: (i) ACE-2 converts angiotensinogen to angiotensin(1-7) (hepatapeptide) which produces neuroprotective action; (ii) ACE inhibitors downregulate kinin B1 receptors in the peripheral nervous system which is responsible for neuropathic pain. However, more extensive research is required in the field of neuropathic pain for the utilization of ACE inhibitors in human.
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Affiliation(s)
- Parneet Kaur
- Department of Pharmacology and Toxicology, Neurodegenerative Research Division, Akal College of Pharmacy & Technical Education, Mastuana Sahib, Sangrur-148001, Punjab, India
| | - Arunachalam Muthuraman
- Department of Pharmacology and Toxicology, Neurodegenerative Research Division, Akal College of Pharmacy & Technical Education, Mastuana Sahib, Sangrur-148001, Punjab, India
| | - Manjinder Kaur
- Department of Pharmacology and Toxicology, Neurodegenerative Research Division, Akal College of Pharmacy & Technical Education, Mastuana Sahib, Sangrur-148001, Punjab, India
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Wing JJ, Baek J, Sánchez BN, Lisabeth LD, Smith MA, Morgenstern LB, Zahuranec DB. Differences in initial stroke severity between Mexican Americans and non-Hispanic whites vary by age: the Brain Attack Surveillance in Corpus Christi (BASIC) project. Cerebrovasc Dis 2014; 38:362-9. [PMID: 25427748 DOI: 10.1159/000366468] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 08/05/2014] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND A wide variety of racial and ethnic disparities in stroke epidemiology and treatment have been reported. Race-ethnic differences in initial stroke severity may be one important determinant of differences in the outcome after stroke. The overall goal of this study was to move beyond ethnic comparisons in the mean or median severity, and instead investigate ethnic differences in the entire distribution of initial stroke severity. Additionally, we investigated whether age modifies the relationship between ethnicity and initial stroke severity as this may be an important determinant of racial differences in the outcome after stroke. METHODS Ischemic stroke cases were identified from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project. National Institutes of Health Stroke Scale (NIHSS) was determined from the medical record or abstracted from the chart. Ethnicity was reported as Mexican American (MA) or non-Hispanic white (NHW). Quantile regression was used to model the distribution of NIHSS score by age category (45-59, 60-74, 75+) to test whether ethnic differences exist over different quantiles of NIHSS (5 percentile increments). Crude models examined the interaction between age category and ethnicity; models were then adjusted for history of stroke/transient ischemic attack, hypertension, atrial fibrillation, coronary artery disease, and diabetes. RESULTS were adjusted for multiple comparisons. RESULTS There were 4,366 ischemic strokes, with median age 72 (IQR: 61-81), 55% MA, and median NIHSS of 4 (IQR: 2-8). MAs were younger, more likely to have a history of hypertension and diabetes, but less likely to have atrial fibrillation compared to NHWs. In the crude model, the ethnicity-age interaction was not statistically significant. After adjustment, the ethnicity-age interaction became significant at the 85th and 95th percentiles of NIHSS distribution. MAs in the younger age category (45-59) were significantly less severe by 3 and 6 points on the initial NIHSS than NHWs, at the 85th and 95th percentiles, respectively. However, in the older age category (75+), there was a reversal of this pattern; MAs had more severe strokes than NHWs by about 2 points, though not reaching statistical significance. CONCLUSIONS There was no overall ethnic difference in stroke severity by age in our crude model. However, several potentially important ethnic differences among individuals with the most severe strokes were seen in younger and older stroke patients that were not explained by traditional risk factors. Age should be considered in future studies when looking at the complex distributional relationship between ethnicity and stroke severity.
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Affiliation(s)
- Jeffrey J Wing
- Department of Epidemiology, University of Michigan, Ann Arbor, Mich., USA
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