Use of the pRESET LITE thrombectomy device in combined approach for medium vessel occlusions: A multicenter evaluation

PURPOSE

Our purpose was to assess the efficacy and safety of the pRESET LITE stent retriever (Phenox, Bochum, Germany), designed for medium vessel occlusion (MeVO) in acute ischemic stroke (AIS) patients with a primary MeVO.

METHODS

We performed a retrospective analysis of the MAD MT Consortium, an integration of prospectively maintained databases at 37 academic institutions in Europe, North America, and Asia, of AIS patients who underwent mechanical thrombectomy with the pRESET LITE stent retriever for a primary MeVO. We subcategorized occlusions into proximal MeVOs (segments A1, M2, and P1) vs. distal MeVOs/DMVO (segments A2, M3-M4, and P2). We reviewed patient and procedural characteristics, as well as angiographic and clinical outcomes.

RESULTS

Between September 2016 and December 2021, 227 patients were included (50% female, median age 78 [65-84] years), of whom 161 (71%) suffered proximal MeVO and 66 (29%) distal MeVO. Using a combined approach in 96% of cases, successful reperfusion of the target vessel (mTICI 2b/2c/3) was attained in 85% of proximal MeVO and 97% of DMVO, with a median of 2 passes (IQR: 1-3) overall. Periprocedural complications rate was 7%. Control CT at day 1 post-MT revealed a hemorrhagic transformation in 63 (39%) patients with proximal MeVO and 24 (36%) patients with DMVO, with ECASS-PH type hemorrhagic transformations occurring in 3 (1%) patients. After 3 months, 58% of all MeVO and 63% of DMVO patients demonstrated a favorable outcome (mRS 0-2).

CONCLUSION

Mechanical thrombectomy using the pRESET LITE in a combined approach with an aspiration catheter appears effective for primary medium vessel occlusions across several centers and physicians.

Effect of anesthetic strategies on distal stroke thrombectomy in the anterior and posterior cerebral artery

BACKGROUND

Numerous questions regarding procedural details of distal stroke thrombectomy remain unanswered. This study assesses the effect of anesthetic strategies on procedural, clinical and safety outcomes following thrombectomy for distal medium vessel occlusions (DMVOs).

METHODS

Patients with isolated DMVO stroke from the TOPMOST registry were analyzed with regard to anesthetic strategies (ie, conscious sedation (CS), local (LA) or general anesthesia (GA)). Occlusions were in the P2/P3 or A2-A4 segments of the posterior and anterior cerebral arteries (PCA and ACA), respectively. The primary endpoint was the rate of complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3) and the secondary endpoint was the rate of modified Rankin Scale score 0-1. Safety endpoints were the occurrence of symptomatic intracranial hemorrhage and mortality.

RESULTS

Overall, 233 patients were included. The median age was 75 years (range 64-82), 50.6% (n=118) were female, and the baseline National Institutes of Health Stroke Scale score was 8 (IQR 4-12). DMVOs were in the PCA in 59.7% (n=139) and in the ACA in 40.3% (n=94). Thrombectomy was performed under LA±CS (51.1%, n=119) and GA (48.9%, n=114). Complete reperfusion was reached in 73.9% (n=88) and 71.9% (n=82) in the LA±CS and GA groups, respectively (P=0.729). In subgroup analysis, thrombectomy for ACA DMVO favored GA over LA±CS (aOR 3.07, 95% CI 1.24 to 7.57, P=0.015). Rates of secondary and safety outcomes were similar in the LA±CS and GA groups.

CONCLUSION

LA±CS compared with GA resulted in similar reperfusion rates after thrombectomy for DMVO stroke of the ACA and PCA. GA may facilitate achieving complete reperfusion in DMVO stroke of the ACA. Safety and functional long-term outcomes were comparable in both groups.

Dual Antiplatelet Therapy for the Acute Management and Long-term Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack, An Updated Review

To improve the efficacy over antiplatelet monotherapy, dual antiplatelet therapy (DAPT) has been increasingly adopted in the management of non-cardioembolic stroke. For minor ischemic stroke and high-risk transient ischemic attack, the aspirin-clopidogrel combination is now recommended for acute short-term treatment, whereas aspirin-ticagrelor combination may be considered in selected patients, especially those with resistance to clopidogrel. For long-term stroke prevention, aspirin-dipyridamole combination has been used as an alternative to antiplatelet monotherapy, and aspirin or clopidogrel combined with cilostazole may be prescribed for added protection in high-risk patients. In this paper, we review the development of DAPT from a historical perspective and describe the findings from major clinical trials published up until the end of 2023. Using the 2021 American Heart Association guideline for secondary stroke prevention as a basis for our recommendations, we further discuss areas of controversy and more recent developments to provide an updated review for clinicians to consider in their daily practice.

Prevalence and Associations of Cognitive Impairment in Adult Patients with Moyamoya Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Cognitive impairment, and in the long term Alzheimer's disease, vascular, or mixed dementia, are potential complications of moyamoya disease (MMD), of which the prevalence and associations are not well established.

OBJECTIVE

We performed a systematic review and meta-analysis to investigate the prevalence of cognitive impairment in adult patients with MMD as well as its clinical and demographic correlates.

METHODS

We performed a systematic search of four electronic databases: PubMed (MEDLINE), EMBASE, Scopus, and Cochrane Library, profiling studies from inception until 7 May 2023. Clinical data consisting of population characteristics, comorbidities, cognitive assessment tools used, and prevalence of cognitive impairment was extracted.

RESULTS

Seventeen studies were included in the meta-analysis, with a total study population of 1,190 patients. All studies assessed cognition, and the overall prevalence of cognitive impairment in MMD patients was 54.59%. A subgroup analysis identified that the prevalence of executive dysfunction in MMD patients was 31.55%. We performed a meta-regression analysis which identified that cognitive impairment was not associated with age, education level, or a history of ischemic or hemorrhagic stroke.

CONCLUSIONS

A substantial proportion of MMD patients have cognitive impairment, and cognitive impairment was found to have no association with a history of stroke. Further research is necessary to investigate the longitudinal relationship of MMD and cognitive impairment, and the impact of bypass surgery on cognitive impairment.

Genetics in Ischemic Stroke: Current Perspectives and Future Directions

Ischemic stroke is a heterogeneous condition influenced by a combination of genetic and environmental factors. Recent advancements have explored genetics in relation to various aspects of ischemic stroke, including the alteration of individual stroke occurrence risk, modulation of treatment response, and effectiveness of post-stroke functional recovery. This article aims to review the recent findings from genetic studies related to various clinical and molecular aspects of ischemic stroke. The potential clinical applications of these genetic insights in stratifying stroke risk, guiding personalized therapy, and identifying new therapeutic targets are discussed herein.

Association Between Breast Arterial Calcifications and Cardiovascular Disease: A Systematic Review and Meta-analysis

BACKGROUND

Recent studies have shown that breast arterial calcification (BAC) detected on screening mammography is linked to cardiovascular diseases via medial calcification. However, its effect on cardiovascular outcomes remains unclear. Therefore, we conducted a meta-analysis to determine the effect of BAC on cardiovascular outcomes in patients.

METHODS

Three electronic databases (Pubmed, Embase, and Scopus) were searched on May 1, 2022, for studies examining the relationship between BAC and cardiovascular outcomes including cardiac death, acute myocardial infarction, ischemic heart disease, stroke, peripheral artery disease, and heart failure. A random-effects meta-analysis model was used to summarise the studies.

RESULTS

A total of 5 longitudinal studies were included with a combined cohort of 87,865 patients. Significantly, the pooled risk ratio (RR) of the association between BAC and cardiac death was 2.06 (P < 0.00001). BAC was associated with a significantly increased risk of developing other cardiovascular diseases, such as ischemic/hemorrhagic stroke (RR 1.51; P = 0.003), ischemic stroke (RR 1.82; P < 0.00001), peripheral vascular disease (RR 1.24; P = 0.003), and heart failure (RR 1.84; P < 0.00001). There was no significant relationship for developing myocardial infarction or for total cardiovascular diseases.

CONCLUSIONS

Our findings suggest that BAC was associated with an increased risk of cardiovascular mortality, and certain cardiovascular outcomes. There is thus a potential to use BAC as a sex-specific cardiovascular risk assessment tool. Furthermore, there is a need for more widespread reporting of BAC to better understand the pathophysiologic mechanisms behind its correlation with cardiovascular disease and to apply it in clinical practice.

Platform for the interdisciplinary study of cardiovascular, metabolic and neurovascular diseases (PICMAN) protocol

Through extensive multisystem phenotyping, the central aim of Project PICMAN is to correlate metabolic flexibility to measures of cardiometabolic health, including myocardial diastolic dysfunction, coronary and cerebral atherosclerosis, body fat distribution and severity of non-alcoholic fatty liver disease. This cohort will form the basis of larger interventional trials targeting metabolic inflexibility in the prevention of cardiovascular disease. Participants aged 21-72 years with no prior manifest atherosclerotic cardiovascular disease (ASCVD) are being recruited from a preventive cardiology clinic and an existing cohort of non-alcoholic fatty liver disease (NAFLD) in an academic medical centre. A total of 120 patients will be recruited in the pilot phase of this study and followed up for 5 years. Those with 10-year ASCVD risk ≥ 5% as per the QRISK3 calculator are eligible. Those with established diabetes mellitus are excluded. Participants recruited undergo a detailed assessment of health behaviours and physical measurements. Participants also undergo a series of multimodality clinical phenotyping comprising cardiac tests, vascular assessments, metabolic tests, liver and neurovascular testing. Blood samples are also being collected and banked for plasma biomarkers, 'multi-omics analyses' and for generation of induced pluripotent stem cells (iPSC). Extensive evidence points to metabolic dysregulation as an early precursor of cardiovascular disease, particularly in Asia. We hypothesise that quantifiable metabolic inflexibility may be representative of an individual in his/her silent, but high-risk progression towards insulin resistance, diabetes and cardiovascular disease. The platform for interdisciplinary cardiovascular-metabolic-neurovascular diseases (PICMAN) is a pilot, prospective, multi-ethnic cohort study.

Association Between Calcium Supplementation and the Risk of Cardiovascular Disease and Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

Some observational studies and randomised controlled trials (RCTs) have reported an association between calcium supplementation and increased risk of cardiovascular disease. Previous meta-analyses on the topic, based on data from RCTs and observational studies, have contradictory findings. This meta-analysis was conducted to determine the difference in associated risks of calcium supplementation with cardiovascular disease and stroke in RCTs.

METHODS

Relevant studies published from database inception to 6 August 2021 were sourced from PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials. Any RCTs focusing on the relationship between calcium supplementation and incidence of cardiovascular disease or stroke were included. Articles were screened independently by two authors, according to the PICO criteria, with disagreements resolved by a third author.

RESULTS

Twelve RCTs were included in the meta-analysis. Calcium supplementation was not associated with myocardial infarction, total stroke, heart failure admission, and all-cause/cardiovascular mortality. Subgroup analysis focusing on calcium monotherapy/calcium co-therapy with vitamin D, female sex, follow-up duration, and geographical region did not affect the findings.

CONCLUSION

Calcium supplementation was not associated with myocardial infarction, total stroke, heart failure admission, and cardiovascular/all-cause mortality. Further studies are required to examine and understand these associations.

Bridging thrombolysis improves survival rates at 90 days compared with direct mechanical thrombectomy alone in acute ischemic stroke due to basilar artery occlusion: a systematic review and meta-analysis of 1096 patients

BACKGROUND

Mechanical thrombectomy (MT) is an effective treatment for patients with acute ischemic stroke (AIS) from basilar artery occlusion (BAO).

OBJECTIVE

To compare the clinical outcomes of MT, with and without bridging intravenous thrombolysis (IVT), in acute BAO through a systematic review and meta-analysis of the current literature.

METHODS

Systematic searches of Medline, EMBASE, and Cochrane Central were undertaken on August 1, 2022. Good functional outcome defined as 90-day modified Rankin Scale score 0-2 was the primary outcome measure. Secondary outcome measures were 90-day mortality, successful post-thrombectomy recanalization (modified Thrombolysis in Cerebral Infarction score ≥2b), symptomatic intracranial hemorrhage (sICH), and subarachnoid hemorrhage (SAH).

RESULTS

Three studies reporting 1096 patients with BAO AIS were included in the meta-analysis. No significant differences in good functional outcome were detected between the two groups (RR=1.28 (95% CI 0.86 to 1.92); p=0.117). However, specifically patients with large artery atherosclerosis (LAA) benefited from bridging IVT (OR=2.52 (95% CI 1.51 to 4.22); p<0.001) with better functional outcomes. There was a significantly lower 90-day mortality rate for patients who underwent bridging IVT compared with MT alone (RR=0.70 (95% CI 0.62 to 0.80); p=0.008). No significant differences were detected in rates of post-treatment recanalization (RR=1.01 (95% CI 0.35 to 2.91); p=0.954), sICH (RR=0.96 (95% CI 0.66 to 1.42); p=0.724), and SAH (RR=0.93 (95% CI 0.31 to 2.83); p=0.563).

CONCLUSIONS

In patients with AIS due to BAO, bridging IVT was associated with lower mortality rates at 90 days, compared with direct MT. There were no improved functional outcomes or increased sICH or SAH between both arms, However, patients with LAA benefited from bridging IVT, with better functional outcomes.

Acute Myocardial Infarction and Risk of Cognitive Impairment and Dementia: A Review

Cognitive impairment (CI) shares common cardiovascular risk factors with acute myocardial infarction (AMI), and is increasingly prevalent in our ageing population. Whilst AMI is associated with increased rates of CI, CI remains underreported and infrequently identified in patients with AMI. In this review, we discuss the evidence surrounding AMI and its links to dementia and CI, including pathophysiology, risk factors, management and interventions. Vascular dysregulation plays a major role in CI, with atherosclerosis, platelet activation, microinfarcts and perivascular inflammation resulting in neurovascular unit dysfunction, disordered homeostasis and a dysfunctional neurohormonal response. This subsequently affects perfusion pressure, resulting in enlarged periventricular spaces and hippocampal sclerosis. The increased platelet activation seen in coronary artery disease (CAD) can also result in inflammation and amyloid-β protein deposition which is associated with Alzheimer's Dementia. Post-AMI, reduced blood pressure and reduced left ventricular ejection fraction can cause chronic cerebral hypoperfusion, cerebral infarction and failure of normal circulatory autoregulatory mechanisms. Patients who undergo coronary revascularization (percutaneous coronary intervention or bypass surgery) are at increased risk for post-procedure cognitive impairment, though whether this is related to the intervention itself or underlying cardiovascular risk factors is debated. Mortality rates are higher in dementia patients with AMI, and post-AMI CI is more prevalent in the elderly and in patients with post-AMI heart failure. Medical management (antiplatelet, statin, renin-angiotensin system inhibitors, cardiac rehabilitation) can reduce the risk of post-AMI CI; however, beta-blockers may be associated with functional decline in patients with existing CI. The early identification of those with dementia or CI who present with AMI is important, as subsequent tailoring of management strategies can potentially improve outcomes as well as guide prognosis.

Enhanced external counter pulsation therapy in patients with symptomatic and severe intracranial steno-occlusive disease: a randomized clinical trial protocol

Intracranial stenosis is prevalent among Asians and constitutes a common cause of cerebral ischemia. While the best medical therapy carries stroke recurrence rates in excess of 10% per year, trials with intracranial stenting have been associated with unacceptable peri-procedural ischemic events. Cerebral ischemic events are strongly related to the severity of intracranial stenosis, which is high in patients with severe intracranial stenosis with poor vasodilatory reserve. Enhanced External Counter Pulsation (EECP) therapy is known to improve myocardial perfusion by facilitating the development of collateral blood vessels in the heart. In this randomized clinical trial, we evaluate whether EECP therapy may be useful in patients with severe stenosis of intracranial internal carotid (ICA) or middle cerebral artery (MCA). The review of literature, methods of evaluation, status of currently used therapeutic approaches, and trial protocol have been presented.

Clinical trial registration

ClinicalTrials.gov, Identifier: NCT03921827.

Left Ventricular Ejection Fraction Association with Acute Ischemic Stroke Outcomes in Patients Undergoing Thrombolysis

(1) Background: Little is known about how left ventricular systolic dysfunction (LVSD) affects functional and clinical outcomes in acute ischemic stroke (AIS) patients undergoing thrombolysis; (2) Methods: A retrospective observational study conducted between 2006 and 2018 included 937 consecutive AIS patients undergoing thrombolysis. LVSD was defined as left ventricular ejection fraction (LVEF) < 50%. Univariate and multivariate binary logistic regression analysis was performed for demographic characteristics. Ordinal shift regression was used for functional modified Rankin Scale (mRS) outcome at 3 months. Survival analysis of mortality, heart failure (HF) admission, myocardial infarction (MI) and stroke/transient ischemic attack (TIA) was evaluated with a Cox-proportional hazards model; (3) Results: LVSD patients in comparison with LVEF ≥ 50% patients accounted for 190 and 747 patients, respectively. LVSD patients had more comorbidities including diabetes mellitus (100 (52.6%) vs. 280 (37.5%), p < 0.001), atrial fibrillation (69 (36.3%) vs. 212 (28.4%), p = 0.033), ischemic heart disease (130 (68.4%) vs. 145 (19.4%), p < 0.001) and HF (150 (78.9%) vs. 46 (6.2%), p < 0.001). LVSD was associated with worse functional mRS outcomes at 3 months (adjusted OR 1.41, 95% CI 1.03-1.92, p = 0.030). Survival analysis identified LVSD to significantly predict all-cause mortality (adjusted HR [aHR] 3.38, 95% CI 1.74-6.54, p < 0.001), subsequent HF admission (aHR 4.23, 95% CI 2.17-8.26, p < 0.001) and MI (aHR 2.49, 95% CI 1.44-4.32, p = 0.001). LVSD did not predict recurrent stroke/TIA (aHR 1.15, 95% CI 0.77-1.72, p = 0.496); (4) Conclusions: LVSD in AIS patients undergoing thrombolysis was associated with increased all-cause mortality, subsequent HF admission, subsequent MI and poorer functional outcomes, highlighting a need to optimize LVEF.

Functional and Mortality Outcomes with Medical and Surgical Therapy in Malignant Posterior Circulation Infarcts: A Systematic Review

BACKGROUND

There remains uncertainty regarding optimal definitive management for malignant posterior circulation infarcts (MPCI). While guidelines recommend neurosurgery for malignant cerebellar infarcts that are refractory to medical therapy, concerns exist about the functional outcome and quality of life after decompressive surgery.

OBJECTIVE

This study aims to evaluate the outcomes of surgical intervention compared to medical therapy in MPCI.

METHODS

In this systematic review, MEDLINE, Embase and Cochrane databases were searched from inception until 2 April 2021. Studies were included if they involved posterior circulation strokes treated with neurosurgical intervention and reported mortality and functional outcome data. Data were collected according to PRISMA guidelines.

RESULTS

The search yielded 6677 studies, of which 31 studies (comprising 723 patients) were included for analysis. From the included studies, we found that surgical therapy led to significant differences in mortality and functional outcomes in patients with severe disease. Neurological decline and radiological criteria were often used to decide the timing for surgical intervention, as there is currently limited evidence for preventative neurosurgery. There is also limited evidence for the superiority of one surgical modality over another.

CONCLUSION

For patients with MPCI who are clinically stable at the time of presentation, in terms of mortality and functional outcome, surgical therapy appears to be equivocal to medical therapy. Reliable evidence is lacking, and further prospective studies are rendered.

Outcomes of Investigating T Wave Inversion With Echocardiography in an Unselected Young Male Preparticipation Cohort

BACKGROUND Electrocardiography (ECG) may be performed as part of preparticipation sports screening. Recommendations on screening of athletes to identify individuals with previously unrecognized cardiac disease are robust; however, data guiding the preparticipation screening of unselected populations are scarce. T wave inversion (TWI) on ECG may suggest an undiagnosed cardiomyopathy. This study aims to describe the prevalence of abnormal TWI in an unselected young male cohort and the outcomes of an echocardiography-guided approach to investigating these individuals for structural heart diseases, focusing on the yield for cardiomyopathies. METHODS AND RESULTS Consecutive young male individuals undergoing a national preparticipation cardiac screening program for 39 months were studied. All underwent resting supine 12-lead ECG. Those manifesting abnormal TWI, defined as negatively deflected T waves of at least 0.1 mV amplitude in any 2 contiguous leads, underwent echocardiography. A total of 69 714 male individuals with a mean age of 17.9±1.1 years were studied. Of the individuals, 562 (0.8%) displayed abnormal TWI. This was most frequently observed in the anterior territory and least so in the lateral territory. A total of 12 individuals (2.1%) were diagnosed with a cardiomyopathy. Cardiomyopathy diagnoses were significantly associated with deeper maximum TWI depth and the presence of abnormal TWI in the lateral territory, but not with abnormal TWI in the anterior and inferior territories. No individual presenting with TWI restricted to solely leads V1 to V2, 2 inferior leads or both was diagnosed with a cardiomyopathy. CONCLUSIONS Cardiomyopathy diagnoses were more strongly associated with certain patterns of abnormal TWI. Our findings may support decisions to prioritize echocardiography in these individuals.

Low incidence of neurological recurrent side-effects following COVID-19 reimmunization

BACKGROUND

Individuals who suffered a neurological adverse event after the Coronavirus disease (COVID-19) vaccine could hesitate and defer reimmunization.

AIM

We examine the risk of recurrence following reimmunization among patients who developed a neurological event after the first dose of the COVID-19 mRNA vaccine.

DESIGN

Observational study.

METHODS

Individuals who developed an adjudicated neurological adverse event (based on Brighton Collaboration criteria) within 6 weeks of the first dose of the COVID-19 vaccine requiring hospitalization were enrolled into a multicenter national registry in Singapore. Neurological recurrence, defined by the development of another neurological event within 6 weeks of the second vaccine dose, was reviewed. Clinical characteristics were compared between patients who chose to proceed or withhold further vaccination, and between those who received timely (3-6 weeks) or delayed (>6 weeks) reimmunization.

RESULTS

From 235 patients (median age, 67 years; 63% men) who developed an adjudicated neurological event after their first dose of mRNA vaccine between 30 December 2020 and 20 April 2021, 181 (77%) chose to undergo reimmunization. Those who decided against reimmunization were older (median age, 74 vs. 66 years) and had greater physical disability following their primary neurological event (46% vs. 20%, P < 0.001). Patients who suffered greater physical disability were three times more likely to delay their reimmunization (odds ratio 3.36, 95% confidence interval: 1.76-6.40). Neurological recurrence was observed in only four individuals (three with seizures and one with myasthenia gravis exacerbation).

CONCLUSIONS

A prior neurological event should not necessarily preclude reimmunization and the decision to proceed with reimmunization should consider the overwhelming benefits conferred by vaccination toward ending this pandemic.

Clustering of Environmental Parameters and the Risk of Acute Ischaemic Stroke

Acute ischaemic stroke (AIS) risk on days with similar environmental profiles remains unknown. We investigated the association between clusters of days with similar environmental parameters and AIS incidence in Singapore. We grouped calendar days from 2010 to 2015 with similar rainfall, temperature, wind speed, and Pollutant Standards Index (PSI) using k-means clustering. Three distinct clusters were formed 'Cluster 1' containing high wind speed, 'Cluster 2' having high rainfall, and 'Cluster 3' having high temperatures and PSI. We aggregated the number of AIS episodes over the same period with the clusters and analysed their association using a conditional Poisson regression in a time-stratified case-crossover design. Comparing the three clusters, Cluster 3 had the highest AIS occurrence (IRR 1.09; 95% confidence interval (CI) 1.05-1.13), with no significant difference between Clusters 1 and 2. Subgroup analyses in Cluster 3 showed that AIS risk was amplified in the elderly (≥65 years old), non-smokers, and those without a history of ischaemic heart disease/atrial fibrillation/vascular heart disease/peripheral vascular disease. In conclusion, we found that AIS incidence may be higher on days with higher temperatures and PSI. These findings have important public health implications for AIS prevention and health services delivery during at-risk days, such as during the seasonal transboundary haze.

Combined balloon guide catheter, aspiration catheter, and stent retriever technique versus balloon guide catheter and stent retriever alone technique: a systematic review and meta-analysis

BACKGROUND

The use of a combination of balloon guide catheter (BGC), aspiration catheter, and stent retriever in acute ischemic stroke thrombectomy has not been shown to be better than a stent retriever and BGC alone, but this may be due to a lack of power in these studies. We therefore performed a meta-analysis on this subject.

METHODS

A systematic literature search was performed on PubMed, Scopus, Embase/Ovid, and the Cochrane Library from inception to October 20, 2021. Our primary outcomes were the rate of successful final reperfusion (Treatment in Cerebral Ischemia (TICI) 2c-3) and first pass effect (FPE, defined as TICI 2c-3 in a single pass). Secondary outcomes were 3 month functional independence (modified Rankin Scale score of 0-2), mortality, procedural complications, embolic complications, and symptomatic intracranial hemorrhage (SICH). A meta-analysis was performed using RevMan 5,4, and heterogeneity was assessed using the I² test.

RESULTS

Of 1629 studies identified, five articles with 2091 patients were included. For the primary outcomes, FPE (44.9% vs 45.4%, OR 1.04 (95% CI 0.90 to 1.22), I²=57%) or final successful reperfusion (64.5% vs 68.6%, OR 0.98 (95% CI 0.81% to 1.20%), I²=85%) was similar between the combination technique and stent retriever only groups. However, the combination technique had significantly less rescue treatment (18.8% vs 26.9%; OR 0.70 (95% CI 0.54 to 0.91), I²=0%). This did not translate into significant differences in secondary outcomes in functional outcomes, mortality, emboli, complications, or SICH.

CONCLUSION

There was no significant difference in successful reperfusion and FPE between the combined techniques and the stent retriever and BGC alone groups. Neither was there any difference in functional outcomes, complications, or mortality.

Sex-based comparisons of clinical characteristics and outcomes of patients with embolic stroke of undetermined source with implantable loop recorders

Funding Acknowledgements

Type of funding sources: None.

Introduction

Embolic strokes of undetermined source (ESUS) constitute a significant proportion of all ischemic strokes, but sex-based comparisons of clinical characteristics and outcomes of ESUS patients have not been well explored. As such, we aimed to examine how sex influences outcomes of ESUS patients.

Methods

Retrospective cohort study performed on consecutive ESUS patients with an implanted ILR between December 2013 to September 2021. We obtained information on the patients’ characteristics, treatments, and outcomes from the electronic medical records. Cox regression was used to investigate whether sex was independently associated with outcomes.

Results

There were 176 patients included in this study. The mean duration of follow-up was 1254 ± 724 days. Mean age was 60.8 ± 12.0 and 47 (26.7%) of patients were female. On univariable Cox regression analysis for subsequent atrial fibrillation (AF) on implantable loop recorder (ILR), patients with subsequent AF on ILR were more likely to be female (HR 2.19, 95% CI 1.04–4.63, p = 0.040), older (HR 1.07, 95% CI 1.03–1.12, p = 0.001), have a lower glomerular filtration rate (eGFR) (HR 0.98, 95% CI 0.97– 0.99, p = 0.004), and have previous percutaneous coronary intervention (PCI) (HR 2.60, 95% CI 1.05–6.46, p = 0.039). On multivariable Cox regression, after adjustment for age, eGFR and previous PCI status, female sex remained independently associated with the development of subsequent AF on ILR. Female sex was not associated with other outcomes including mortality, subsequent acute myocardial infarction, stroke/transient ischemic attack and heart failure.

Conclusions

In this cohort of ESUS patients with ILR implantation, female sex was independently associated with a higher risk of development of AF on ILR. However, female sex was not a predictor of mortality, subsequent acute myocardial infarction, stroke/transient ischemic attack and heart failure.

Association of Shunt Size and Long-Term Clinical Outcomes in Patients with Cryptogenic Ischemic Stroke and Patent Foramen Ovale on Medical Management

INTRODUCTION

Patent foramen ovale (PFO) is a potential source of cardiac embolism in cryptogenic ischemic stroke, but it may also be incidental. Right-to-left shunt (RLS) size may predict PFO-related stroke, but results have been controversial. In this cohort study of medically-managed PFO patients with cryptogenic stroke, we aimed to investigate the association of shunt size with recurrent stroke, mortality, newly detected atrial fibrillation (AF), and to identify predictors of recurrent stroke.

METHODS

Patients with cryptogenic stroke who screened positive for a RLS using a transcranial Doppler bubble study were included. Patients who underwent PFO closure were excluded. Subjects were divided into two groups: small (Spencer Grade 1, 2, or 3; n = 135) and large (Spencer Grade 4 or 5; n = 99) shunts. The primary outcome was risk of recurrent stroke, and the secondary outcomes were all-cause mortality and newly detected AF.

RESULTS

The study cohort included 234 cryptogenic stroke patients with medically-managed PFO. The mean age was 50.5 years, and 31.2% were female. The median period of follow-up was 348 (IQR 147-1096) days. The rate of recurrent ischemic stroke was higher in patients with large shunts than in those with small shunts (8.1% vs. 2.2%, p = 0.036). Multivariate analyses revealed that a large shunt was significantly associated with an increased risk of recurrent ischemic stroke [aOR 4.09 (95% CI 1.04-16.0), p = 0.043].

CONCLUSIONS

In our cohort of cryptogenic stroke patients with medically managed PFOs, those with large shunts were at a higher risk of recurrent stroke events, independently of RoPE score and left atrium diameter.

Abnormal left atrial strain is associated with eventual diagnosis of atrial fibrillation in patients with embolic stroke of undetermined source

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with embolic stroke of undetermined source (ESUS) have no immediate attributable cause despite initial evaluation. Occult paroxysmal atrial fibrillation (pAF) diagnosed on prolonged electrocardiographic monitoring may be subsequently found in 20% of patients initially classified as ESUS [1]. Anatomic and functional alterations of left atrium (LA) are known to predict pAF in the general population [2]. Recent studies have suggested that LA dysfunction is linked to the risk of development of pAF in stroke patients and may precede LA enlargement [1]. LA strain analysis may be helpful to predict the development of pAF as it can detect subclinical functional impairment [2]. The aim of this study was to analyse whether LA strain can be a marker for the development of new-onset AF in patients with ESUS and sinus rhythm.

Methods

Our single-centre observational cohort study examined 157 patients hospitalised for ESUS in our tertiary hospital between October 2014 and October 2017 who underwent AF monitoring with an implantable loop recorder (ILR). These patients were followed up for occurrence of new-onset pAF and recurrence of ischaemic stroke. All patients underwent transthoracic echocardiography (TTE) during index hospitalisation as part of the workup for ESUS. Echocardiographic images were obtained and analysed post-hoc for two-dimensional (2D) speckle tracing deformation parameters. These LA strain parameters were analysed against the primary outcome of AF detection and secondary outcome of recurrent ischaemic stroke.

Results

A total of 157 ESUS patients, with a mean age of 61.0 (±11.6) years, were followed up for a median duration of 3.5 (interquartile range 3.29) years. ILR monitoring detected AF in 27 patients (17.2%). 27 patients developed recurrent ischaemic strokes. Of the 27 patients with newly diagnosed AF on ILR, 24 (88.9%) were commenced on oral anticoagulation; the remaining 3 patients were not on anticoagulation due to high bleeding risk and frailty.

Patients who had newly diagnosed AF had more impaired left atrial reservoir strain (LASr; 23.5% ± 10.3%, P = 0.042) and left atrial conduit strain (LAScd; -10.5% ± 5.3%, P = 0.003) compared with patients who remained in sinus rhythm. Multivariable logistic regression analysis adjusting for age, sex, hypertension, hyperlipidaemia, diabetes mellitus and left ventricular ejection fraction (LVEF) showed that LAScd was associated with occult AF (adjusted odds ratio [aOR] = 1.110, 95% CI, 1.019-1.209, P = 0.017) and the composite outcome of AF and recurrent ischaemic stroke (OR = 1.069, 95% CI, 1.014-1.138, P = 0.038). Abnormal LAScd was significantly associated with occult AF even when stratified by normal LA volume index (LAVI) (OR = 2.672, 95% CI, 1.035-8.548, P = 0.048) and high LAVI (OR = 1.713, 95% CI, 1.023-2.869, P = 0.041).

Conclusion

Impaired left atrial strain was associated with occult AF detection in patients with ESUS undergoing ILR monitoring.

Characteristics and outcomes of aortic stenosis patients with and without stroke

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Sia CH was supported by the National University of Singapore Yong Loo Lin School of Medicine’s Junior Academic Faculty Scheme

Background

Aortic stenosis (AS) is related to several atherosclerosis risk factors and is associated with an increased risk of ischaemic stroke. Some reports suggest that aortic valve calcification may predispose to embolic stroke although this is not well-studied. The literature is also sparse regarding individual stroke subtypes and predictors of stroke in AS.

Purpose

We aimed to 1) Describe rates of ischaemic stroke in AS including specific stroke subtypes; 2) Compare clinical and echocardiographic characteristics of patients with AS who subsequently developed ischaemic stroke versus those who did not, and 3) Identify independent variables associated with subsequent stroke in AS.

Methods

Patients with AS were recruited from an echocardiography database from September 2011 to December 2015 at a single tertiary centre. The primary study endpoint was acute ischaemic stroke. Clinical characteristics and echocardiographic parameters were compared between patients who suffered a stroke after AS diagnosis and those who did not. Multivariable Cox regression analysis was used to identify factors associated with subsequent stroke.

Results

A total of 703 patients with AS were studied, with a median follow-up duration of 3.0 (IQR 0.5, 5.0) years. Twenty-two patients (3.1%) developed stroke following AS diagnosis (large vessel, 18.2%; cardioembolic, 50.0%; small vessel, 18.2%; other determined ischaemic stroke, 13.6%). These patients had a greater prevalence of previous stroke or transient ischaemic attack (TIA) (50.0%) compared to patients who did not develop subsequent stroke (20.9%), p&lt;0.001. Patients with AS who developed subsequent stroke also more commonly had atrial fibrillation at the time of indexed echocardiography (40.0%) compared to their counterparts who did not develop stroke (13.5%), p=0.004 (Table 1). Other cardiovascular risk factors and traditional echocardiographic parameters of AS severity were similar between the 2 groups. Degenerative calcified aortic valve was not associated with the development of all types of ischaemic stroke or cardioembolic stroke. AS severity was also not associated with development of stroke. Multivariable Cox regression analysis found previous stroke or TIA (HR 8.00, 95% CI 2.70–23.58, p&lt;0.001) and atrial fibrillation at time of echocardiography (HR 8.81, 95% CI 1.34–10.80, p=0.012) to be independent predictors of subsequent stroke in AS. The key findings of our study are summarised in Figure 1.

Conclusions

Cardioembolic stroke is the most common stroke subtype in patients with AS. Previous history of stroke or TIA and atrial fibrillation at time of diagnostic echocardiography are independent predictors of subsequent stroke in AS. Calcified aortic valve was not found to be a risk factor for all types of ischaemic stroke or cardioembolic stroke.

Interplay between post-myocardial infarction ejection fraction and atrial fibrillation: implications for ischemic stroke

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Singapore Ministry of Health’s National Medical Research Council

Background

There are little data on the interplay between post-acute myocardial infarction (MI), left ventricular systolic dysfunction and atrial fibrillation (AF) and the impact on subsequent acute ischemic stroke (AIS), particularly among patients with moderately reduced ejection fraction (EF).

Purpose

We aimed to study the association between low EF, AF and the risk and severity of AIS.

Methods

This study linked national, population-based data from the Singapore Myocardial Infarction Registry with the Singapore Stroke Registry from 2007 to 2018. The EF and AF status were recorded during the index MI hospitalization. Patients were grouped based on an EF of ≥50% or &lt;50%. An additional grouping of patients with AMI in 2008 to 2018 and EF of ≥50% (normal EF), 40-49% (mildly reduced EF) or &lt;40% (reduced EF) was done. The primary outcome of interest was the risk of developing an AIS after an AMI. The secondary outcome of interest was the National Institute of Health Stroke Scale (NIHSS) across the different strata of EF among AMI patients with subsequent AIS.

Results

There were 64512 patients available for analysis. The median age was 65.7 and 69.5% were male. The median duration from MI to AIS was 16.9 (IQR 1.6-46.1) months. Low EF &lt;40% was independently associated with subsequent AIS (adjusted HR 1.18, 95% CI 1.10-1.27), as was EF 40-49% (adjusted HR 1.16, 95% CI 1.06-1.27). Among patients with AF, EF&lt;50% was not a statistically significant predictor of AIS (adjusted HR 1.08, 95% CI 0.96-1.23). In patients without AF, the mildly reduced EF group had an increased aHR of AIS of 1.18 (95% CI 1.06-1.31), but not those with AF (aHR 1.03, 95% CI 0.87-1.23). The cubic spline curves of continuous EF against relative hazard for stroke stratified by presence of AF is shown in Figure 1. Patients with low EF without AF had highest median NIHSS score during subsequent AIS (EF &lt;40% NIHSS 6-9; EF 40-49% NIHSS 4; EF ≥50% NIHSS 4).

Conclusions

Reduced and moderately reduced EF post-MI was independently associated with subsequent AIS and was associated with increased AIS severity in patients without AF but not in those with AF. Further research is needed to mitigate the risk of late AIS among post-MI patients with reduced EF along with AF.

Risk of Liver Fibrosis Is Associated with More Severe Strokes, Increased Complications with Thrombolysis, and Mortality

The Fibrosis (FIB)-4 index is an established non-invasive test to detect liver fibrosis. Liver fibrosis is postulated to be one of the predictors of the risk of symptomatic Intracranial Haemorrhage (SICH) after intravenous tissue plasminogen activator (IV tPA) therapy, the mainstay of treatment following acute ischemic stroke (AIS). However, SICH is a feared complication of thrombolytic therapy. We aimed to evaluate the association of FIB-4 with outcomes of AIS after IV tPA. Consecutive AIS patients receiving IV tPA from 2006 to 2018 at a single stroke centre were studied in a retrospective cohort study. Multivariable adjusted logistic regression was performed to assess associations of FIB-4 with outcomes. The primary outcome was SICH, and secondary outcomes included functional independence (mRS of 0−2) and mortality measured at 90 days. Among 887 patients (median age: 67 (IQR: 57−77)), 342 had FIB-4 < 1.3 and 161 had FIB-4 > 2.67. A greater proportion of moderate to severe strokes (NIHSS ≥10) occurred in the FIB-4 > 2.67 group (n = 142, 88.8%) compared to the FIB-4 < 1.3 group (n = 208, 61.2%). Amongst the different stroke subtypes, median FIB-4 was highest in cardioembolic stroke (CES) compared to the 3 other non-CES stroke subtypes (1.90 (IQR: 1.41−2.69)). Following IV tPA, having FIB-4 > 2.67 was associated with an increased rate of SICH (adjusted OR: 4.09, 95% CI: 1.04−16.16, p = 0.045) and increased mortality (adjusted OR 3.05, 95% CI: 1.28−7.26, p = 0.012). Advanced liver fibrosis was associated with an increased rate of SICH and increased 90-day mortality after IV tPA. The FIB-4 score may be useful for prognostication after IV tPA.

Potential Embolic Sources in Embolic Stroke of Undetermined Source Patients with Patent Foramen Ovale

INTRODUCTION

A patent foramen ovale (PFO) may coexist with other potential embolic sources (PESs) in patients with embolic stroke of undetermined source (ESUS), leading to difficulty in attributing the stroke to either the PFO or other PESs. We aimed to investigate the prevalence and predictors of concomitant PESs in ESUS patients with PFOs.

METHODS

A retrospective cohort study was conducted in a tertiary stroke centre. Consecutive patients with ESUS and a concomitant PFO admitted between 2012 and 2021 were included in the study. Baseline characteristics and investigations as a part of stroke workup including echocardiographic and neuroimaging data were collected. PESs were adjudicated by 2 independent neurologists after reviewing the relevant workup.

RESULTS

Out of 1,487 ESUS patients, a total of 309 patients who had a concomitant PFO with mean age of 48.8 ± 13.2 years were identified during the study period. The median Risk of Paradoxical Embolism (RoPE) score for the study cohort was 6 (IQR 5-7.5). Of the 309 patients, 154 (49.8%) only had PFO, 105 (34.0%) patients had 1 other PES, 34 (11.0%) had 2 PES, and 16 (5.2%) had 3 or more PES. The most common PESs were atrial cardiopathy (23.9%), left ventricular dysfunction (22.0%), and cardiac valve disease (12.9%). The presence of additional PESs was associated with age ≥60 years (p < 0.001), RoPE score ≤6 (p ≤0.001), and the presence of comorbidities including diabetes mellitus (p = 0.004), hypertension (p≤ 0.001), and ischaemic heart disease (p = 0.011).

CONCLUSION

A large proportion of ESUS patients with PFOs had concomitant PESs. The presence of concomitant PESs was associated with older age and a lower RoPE score. Further, large cohort studies are warranted to investigate the significance of the PES and their overlap with PFOs in ESUS.

Clinical characteristics, echocardiographic features and long-term outcomes of patients with ischaemic versus non-ischaemic left ventricular thrombus

Background

Left ventricular thrombus (LVT) may develop in patients following myocardial infarction (MI), as well as in ischaemic and non-ischaemic cardiomyopathies, and may result in acute ischaemic stroke. Smaller studies comparing LVT associated with ischaemic and non-ischaemic aetiologies only reported 1-year outcomes or focused on specific subpopulations. We aimed to compare the clinical and echocardiographic characteristics and longer-term outcomes in a large population of patients with ischaemic versus non-ischaemic LVT.

Methods

This was a retrospective study of 552 consecutive patients with echocardiographically-identified LVT from March 2011 to January 2021 at a tertiary centre. Ischaemic LVT included LVT associated with MI and ischaemic cardiomyopathy. Non-ischaemic LVT included cases without evidence of ischaemia. Echocardiographic images were interpreted by trained cardiologists. We studied thrombus resolution as well as 5-year rates of ischaemic stroke and all-cause mortality.

Results

Of the 552 patients, mean age was 59.9 years and 84.4% were male. 492 patients had ischaemic LVT and 60 patients had non-ischaemic LVT. Ischaemic LVT was associated with older age (60.4 versus 55.3 years), male sex (86.8% versus 65.0%), smoking (49.2% versus 25.0%) and hyperlipidaemia (54.3% versus 28.3%). Left ventricular ejection fraction (LVEF) was lower in non-ischaemic LVT (28.9% versus 31.9%). LVEF ≤35% was associated with increased mortality in ischaemic LVT (HR 2.11, 95% CI 1.32–3.38). Rates of thrombus resolution, stroke and all-cause mortality were similar in the 2 groups. Anticoagulation was associated with a lower risk of stroke in ischaemic LVT (HR 0.32, 95% CI 0.16–0.66) and lower mortality in both ischaemic (HR 0.44, 95% CI 0.26–0.72) and non-ischaemic LVT (HR 0.14, 95% CI 0.03–0.61).

Conclusion

Patients with ischaemic LVT were more often older, male, smokers and had cardiovascular co-morbidities compared to those with non-ischaemic LVT. Thrombus resolution, stroke and all-cause mortality rates were similar in both groups. Anticoagulation was associated with lower mortality but this needs to be investigated in future prospective studies.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): CHS was supported by the National University of Singapore Yong Loo Lin School of Medicine's Junior Academic Faculty Scheme

Prevalence and incidence of stroke, white matter hyperintensities, and silent brain infarcts in patients with chronic heart failure: A systematic review, meta-analysis, and meta-regression

Introduction

Heart failure (HF) is associated with ischemic stroke (IS). However, there are limited studies on the prevalence of IS, white matter hyperintensities (WMHs), and silent brain infarcts (SBIs). Furthermore, interaction with ejection fraction (EF) is unclear.

Methods

We searched three databases (viz., PubMed, Embase, and Cochrane) for studies reporting the incidence or prevalence of IS, WMHs, and SBIs in HF. A total of two authors independently selected included studies. We used random-effects models, and heterogeneity was evaluated with I2 statistic. Meta-regression was used for subgroup analysis.

Results

In total, 41 articles involving 870,002 patients were retrieved from 15,267 records. Among patients with HF, the pooled proportion of IS was 4.06% (95% CI: 2.94–5.59), and that of WMHs and SBIs was higher at 15.67% (95% CI: 4.11–44.63) and 23.45% (95% CI: 14.53–35.58), respectively. Subgroup analysis of HFpEF and HFrEF revealed a pooled prevalence of 2.97% (95% CI: 2.01–4.39) and 3.69% (95% CI: 2.34–5.77), respectively. Subgroup analysis of WMH Fazekas scores 1, 2, and 3 revealed a decreasing trend from 60.57 % (95% CI: 35.13–81.33) to 11.57% (95% CI: 10.40–12.85) to 3.07% (95% CI: 0.95–9.47). The relative risk and hazard ratio of patients with HF developing IS were 2.29 (95% CI: 1.43–3.68) and 1.63 (95% CI: 1.22–2.18), respectively. Meta-regression showed IS prevalence was positively correlated with decreasing anticoagulant usage.

Conclusion

We obtained estimates for the prevalence of IS, WMH, and SBI in HF from systematic review of the literature.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=255126, PROSPERO [CRD42021255126].

Evaluating the relationship between right-to-left shunt and white matter hyperintensities in migraine patients: A systematic review and meta-analysis

Introduction

White matter hyperintensities (WMHs) have been observed with greater frequency in patients with migraine and are thought to be associated with impaired cognition and function. The relationship between WMHs and right-to-left shunt (RLS) in migraine patients is unknown. We performed a systematic review to determine if there is an association between RLS and WMHs in patients with migraine.

Methods

A systematic search of the literature was performed in PubMed and Embase using a suitable keyword search strategy from inception up to 16th June 2021. All studies that included patients with migraine and studied RLS and WMHs were included.

Results

A total of 8 non-randomized observational studies comprising 1125 patients with migraine were included; 576 had an RLS, compared to 549 patients with no RLS. The mean age of the study populations ranged from 28.4 to 43 years, while the average duration from migraine diagnosis ranged from 5.1 to 19 years. The proportion of female to male patients was consistently higher in all studies (60.0–94.4%). Amongst migraine patients with RLS, 338 patients (58.7%) had WMHs. In contrast, 256 (46.6%) of migraine patients without RLS had WMHs. RLS was significantly associated with the presence of WMHs in migraine patients (OR: 1.56, 95% CI: 1.05–2.34, p = 0.03).

Conclusion

In migraine patients, RLS was significantly associated with the presence of WMHs. Longitudinal studies are warranted to establish RLS as a risk factor for WMHs in patients with migraine, and to establish the significance of these changes.

A systematic review and meta-analysis of non-vitamin K antagonist oral anticoagulants vs vitamin K antagonists after transcatheter aortic valve replacement in patients with atrial fibrillation

PURPOSE

Transcatheter aortic valve replacement (TAVR) is increasingly carried out in patients with aortic valvular conditions. Atrial fibrillation (AF) is a common comorbidity among patients undergoing TAVR. Despite this, there remains a paucity of data and established guidelines regarding anticoagulation use post-TAVR in patients with AF.

METHODS

Four databases were searched from inception until 12 October 2021. A title and abstract sieve, full-text review and data extraction were conducted by independent authors, and articles including patients without AF were excluded. The Review Manager (Version 5.4) was utilised in data analysis.

RESULTS

A total of 25,199 post-TAVR patients with AF were included from seven articles, with 9764 patients on non-vitamin K antagonist oral anticoagulants (NOAC) and 15,435 patients on vitamin K antagonists (VKA). In this analysis, there was a significantly lower risk of all-cause mortality at 1 year (RR: 0.75, CI: 0.58-0.97, p = 0.04, I² = 56%), and bleeding at 1 year (RR: 0.73, CI: 0.68-0.79, p =  < 0.00001, I² = 0%), between patients on NOAC and VKA. There were no detectable differences between patients on NOAC and VKA for all-cause mortality at 2 years, stroke within 30 days, stroke within 1 year, ischaemic stroke at 1 year and life-threatening bleeding at 30 days.

CONCLUSION

While the results of this analysis reveal NOAC as a potential alternate treatment modality to VKA in post-TAVR patients with AF, further research is needed to determine the full safety and efficacy profile of NOAC (PROSPERO: CRD42021283548).

Hearing Impairment in Stroke Patients- Findings from a Pilot Study Conducted in India

Auditory processing difficulties and hearing loss have been reported among stroke survivors, but is largely neglected. Post-stroke hearing impairment may affect communication between stroke survivors and healthcare professionals, thereby restricting rehabilitation and long-term patient outcome. In this prospective pilot study, we sought to determine the prevalence and pattern of hearing loss in stroke patients when compared to age and sex matched controls. 50 consecutive patients with first-ever stroke, both hemorrhagic and ischemic, and a comparison cohort of 50 age and sex matched controls were assessed. Pure Tone Audiogram was performed in all patients within 15 days of stroke onset and mean hearing loss was determined. Mean audiometric threshold was significantly higher in both ears in stroke patients (mean 44.0 ± 12.1 dB) when compared to the control subjects (36.1 ± 11.4 dB; p = 0.001). After adjusting for Diabetes mellitus and hypertension, sensorineural hearing loss was more common and severe in stroke compared to controls (p < 0.005). Most of the strokes were ischemic and involved middle cerebral artery territory. A modest correlation between hearing threshold and stroke severity in both ears was seen (mean B 0.775, R² 0.54, CI 0.122-1.427, p = 0.020). Our pilot study shows significant hearing impairment in patients with stroke, compared to age and sex matched controls with similar prevalence of cardiovascular risk factors, interestingly seen in a predominantly anterior circulation stroke population. Undetected hearing loss may impact post stroke functional recovery. Hence, current rehabilitation guidelines should include auditory screening in all patients of stroke for detection of hearing loss.

The use of colchicine as an anti-inflammatory agent for stroke prevention in patients with coronary artery disease: a systematic review and meta-analysis

OBJECTIVE

The primary objective is to evaluate the use of colchicine as an anti-inflammatory agent for stroke prevention in patients with coronary artery disease.

BACKGROUND

There has been a rising number of randomized controlled trials conducted in patients with coronary artery disease on the use of colchicine in reducing cardiovascular complications. Recent publications suggest colchicine reduces the risk of stroke and other cardiovascular events.

METHODS

We performed a systematic review of known trials in the current literature to characterize the clinical characteristics and outcomes of colchicine treatment in patients with coronary artery disease. A literature search was performed in PubMed, Embase and SCOPUS using a suitable keyword search strategy from inception to 4 June 2021. All studies evaluating cardiovascular outcomes of colchicine treatment in patients with coronary artery disease were included.

RESULTS

The systemic review included 5 randomized controlled trials assessing a total of 11,790 patients. Majority of studies used a colchicine dosing regimen of 0.5 mg once daily, with the median follow-up duration ranging from 6 to 36 months. Meta-analytic estimates for stroke incidence highlighted a statistically significant benefit for patients that were administered colchicine compared to placebo (OR 0.47, 95% CI 0.27-0.81, p = 0.006), and a non-significant benefit for myocardial infarction. There was no significant association between colchicine treatment and the adverse effects of gastrointestinal symptoms and myopathy/myalgia.

CONCLUSIONS

The use of colchicine reduces the risk of stroke in patients with a history of coronary artery disease, without a significant increase in gastrointestinal and myopathy/myalgia adverse effects.

Effect of Sex on Outcomes of Mechanical Thrombectomy in Basilar Artery Occlusion: A Multicentre Cohort Study

INTRODUCTION

Identifying differences in outcome of basilar artery occlusion (BAO) between males and females may be useful in aiding clinical management. Recent studies have demonstrated widespread underrepresentation of women in acute stroke clinical trials. This international multicentre study aimed to determine sex differences in outcome after mechanical thrombectomy (MT) for patients with acute BAO.

METHODS

We performed a retrospective analysis of consecutive patients with BAO who had undergone MT in seven stroke centres across five countries (Singapore, Taiwan, United Kingdom, Sweden, and Germany), between 2015 and 2020. Primary outcome was a favourable functional outcome measured by a modified Ranking Scale (mRS) of 0-3 at 90 days. Secondary outcomes were mRS 0-3 upon discharge, mortality, symptomatic intracranial haemorrhage (sICH) and subarachnoid haemorrhage (SAH).

RESULTS

Among the 322 patients who underwent MT, 206 (64.0%) patients were male and 116 (36.0%) were female. Females were older than males (mean ± SD 70.9 ± 14.3 years vs. 65.6 ± 133.6 years; p = 0.001) and had higher rates of atrial fibrillation (38.9% vs. 24.2%; p = 0.012). Time from groin puncture to reperfusion was shorter in females than males (mean ± SD 57.2 ± 37.2 min vs. 71.1 ± 50.9 min; p = 0.021). Despite these differences, primary and secondary outcome measures were similar in females and males, with comparable rates of favourable 90-day mRS scores (mean ± SD 46 ± 39.7 vs. 71 ± 34.5; OR = 1.20; 95% confidence interval [CI] = 0.59-2.43; p = 0.611), favourable discharge mRS scores (mean ± SD 39 ± 31.6 vs. 43 ± 25.9; OR = 1.38; 95% CI = 0.69-2.78; p = 0.368) and in-hospital mortality (mean ± SD 30 ± 25.9 vs. 47 ± 22.8; OR = 1.15; 95% CI = 0.55-2.43; p = 0.710. Rates of complications such as sICH (mean ± SD 5 ± 4.3 vs. 9 ± 4.4; OR = 0.46; 95% CI = 0.08-2.66; p = 0.385) and SAH (mean ± SD 4 ± 3.4 vs. 5 ± 2.4; OR = 0.29; 95% CI = 0.03-3.09; p = 0.303) comparably low in both groups.

CONCLUSION

Females achieved comparable functional outcomes compared with males after undergoing MT for BAO acute ischemic stroke.

Effect of frailty on outcomes of endovascular treatment for acute ischaemic stroke in older patients

BACKGROUND

frailty has been shown to be a better predictor of clinical outcomes than age alone across many diseases. Few studies have examined the relationship between frailty, stroke and stroke interventions such as endovascular thrombectomy (EVT).

OBJECTIVE

we aimed to investigate the impact of frailty measured by clinical frailty scale (CFS) on clinical outcomes after EVT for acute ischemic stroke (AIS) in older patients ≥70 years.

METHODS

in this retrospective cohort study, we included all consecutive AIS patients age ≥ 70 years receiving EVT at a single comprehensive stroke centre. Patients with CFS of 1-3 were defined as not frail, and CFS > 3 was defined as frail. The primary outcome was modified Rankin Score (mRS) at 90 days. The secondary outcomes included duration of hospitalisation, in-hospital mortality, carer requirement, successful reperfusion, symptomatic intracranial haemorrhage and haemorrhagic transformation.

RESULTS

a total of 198 patients were included. The mean age was 78.1 years and 52.0% were female. Frail patients were older, more likely to be female, had more co-morbidities. CFS was significantly associated with poor functional outcome after adjustment for age, NIHSS and time to intervention (adjusted odds ratio [aOR] 1.54, 95% confidence interval [CI] 1.04-2.28, P = 0.032). There was trend towards higher mortality rate in frail patients (frail: 18.3%; non-frail: 9.6%; P = 0.080). There were no significant differences in other secondary outcomes except increased carer requirement post discharge in frail patients (frail: 91.6%; non-frail: 72.8%; P = 0.002).

CONCLUSIONS

frailty was associated with poorer functional outcome at 90 days post-EVT in patients ≥ 70 years.

The Effect of COVID-19 Endemicity on the Mental Health of Health Workers

Objectives

A major surge in COVID-19 cases despite Singapore's high vaccination has strained the health care system in October 2021. Our aim was to assess and compare Healthcare Worker (HCW) mental well-being in 2021 against a previously published cohort in 2020.

Design

Cross-sectional survey study.

Setting and Participants

HCWs from 4 public hospitals and a primary health care system over a 4-week duration in 2021 coinciding with a major surge compared with a similar period in 2020.

Methods

A survey comprising of the Oldenburg Burnout Inventory (OLBI), Hospital Anxiety and Depression Scale (HADS), and Safety Attitudes Questionnaire (SAQ) was distributed via email. Primary endpoints were the proportion meeting OLBI thresholds for both disengagement and exhaustion and being at risk for both Anxiety and Depression using HADS. Multivariate analysis identified significant predictors among demographic, workplace, and SAQ data. Subgroup analysis of overseas HCWs was performed.

Results

We surveyed 1475 HCWs. Significantly more HCWs met primary outcomes using OLBI and HADS than in 2020 (84.1% and 39.6% vs 68.2% and 23.3%, respectively; P < .001). Burnout levels were uniformly high. A HADS score ≥8 in either subscale was significantly associated with meeting burnout thresholds (P < .001). Overseas HCWs (P = .002), South Asian ethnicity (P = .004), preuniversity educational qualifications (P = .026), and longer shift workhours of 8 to <12 (P = .015) and ≥12 (P = .001) were significantly associated with meeting HADS thresholds. Among overseas HCWs (n=407), seeing family more than a year ago was significantly associated with worse OLBI disengagement scores and a greater proportion meeting HADS thresholds vs seeing them within a year or being local HCWs (47.2% vs 37.2% and 35.6%, respectively; P = .001).

Conclusions and Implications

HCW mental health has objectively worsened between 2020 and 2021 in the pandemic’s second year. Avoiding prolonged shifts, adopting preventive mental health strategies, improving patient safety, and attention to HCWs of minority ethnicity, from overseas, and with preuniversity education may help.

Stress hyperglycaemia is associated with poor functional outcomes in patients with acute ischaemic stroke after intravenous thrombolysis

BACKGROUND

Transient hyperglycaemia in the context of illness with or without known diabetes has been termed as 'stress hyperglycaemia'. Stress hyperglycaemia can result in poor functional outcomes in patients with acute ischaemic stroke (AIS) who underwent mechanical thrombectomy. We investigated the association between stress hyperglycaemia and clinical outcomes in AIS patients undergoing intravenous thrombolysis (IVT).

METHODS

We examined 666 consecutive patients with AIS who underwent IVT from 2006 to 2018. All patients had a glycated haemoglobin level (HbA1c) and fasting venous blood glucose measured within 24 h of admission. Stress hyperglycaemia ratio (SHR) was defined as the ratio of the fasting glucose to the HbA1c. Univariate and multivariate analyses were employed to identify predictors of poor functional outcomes (modified Rankin Scale 3-6 at 3 months) after IVT.

RESULTS

Three-hundred and sixty-one patients (54.2%) had good functional outcomes. These patients tended to be younger (60.7 ± 12.7 vs. 70 ± 14.4 years, P < 0.001), male (70.7% vs. 51.5%, P < 0.001), had lower prevalence of atrial fibrillation (13.0% vs. 20.7%, P = 0.008) and lower SHR (0.88 ± 0.20 vs. 0.99 ± 26, P < 0.001). Patients with high SHR (≥0.97) were slightly older than those with low SHR (<0.97) and were more likely to have diabetes mellitus. On multivariate analysis, higher SHR was independently associated with poor functional outcomes (adjusted odds ratio 3.85, 95% confidence interval 1.59-9.09, P = 0.003).

CONCLUSION

SHR appears to be an important predictor of functional outcomes in patients with AIS undergoing IVT. This may have important implications on the role of glycaemic control in the acute management of ischaemic stroke.

Prevalence and diagnostic yield of investigating t wave inversion in a large unselected pre-participation cohort of young Asian males

Background/Introduction

T wave inversion (TWI) is a potentially abnormal finding on pre-participation screening electrocardiography (ECG), as it may suggest an underlying cardiomyopathy that should be risk stratified appropriately to minimise the risk of sports-related sudden cardiac death. Existing international guidelines prescribe criteria for investigating TWI in athletes. However, it is not established if these criteria can be extrapolated to screening unselected individuals. There is also evidence recommending against investigating specific patterns of anterior TWI in certain subsets of athletes due to low diagnostic yield; whether these exemptions may apply to non-athletes is uncertain. Given the importance of physical activity for primary prevention of cardiovascular disease in the general population, more evidence to guide pre-participation ECG screening of unselected individuals is needed.

Purpose

Firstly, to determine the epidemiology of abnormal TWI in a large unselected pre-participation cohort of young males of predominantly Asian ethnicity. Secondly, to determine the diagnostic yield of an echocardiography-guided approach to investigating individuals with abnormal TWI for a cardiomyopathy.

Methods

All individuals who attended a national centre for pre-enlistment cardiac screening over 39 months from 2017 were examined. Demographic data, anthropometric data and standardised physical fitness test scores were collected. Resting 12-lead ECG was performed for all individuals. Those with abnormal TWI, defined as a negatively deflected T wave of at least 0.1 mV amplitude in two contiguous leads, were referred to tertiary centres for echocardiography.

Results

69,714 consecutive males of mean age 17.9±1.1 years were screened. 562 individuals (0.8%) displayed abnormal TWI. Better aerobic fitness, but not muscular strength, was associated with a higher prevalence of abnormal TWI in general and specifically in the anterior territory, although not beyond leads V1-V2. Aerobic fitness had no association with abnormal TWI in the inferior territory or lateral territory. Of those with abnormal TWI, 12 individuals (2.1%) were newly diagnosed with a cardiomyopathy. Significant factors associated with a cardiomyopathy diagnosis were abnormal TWI in the lateral territory, abnormal TWI in the anterior territory beyond lead V2, deeper maximum TWI depth, presence of hypertension and higher body mass index. No individual presenting with TWI restricted to solely leads V1-V2 and/or two inferior leads without abnormal TWI in other contiguous leads was diagnosed with a cardiomyopathy.

Conclusion

Investigating abnormal TWI in an unselected pre-participation cohort of young Asian males had a significant yield, particularly in individuals manifesting abnormal TWI in the lateral territory and the anterior territory beyond lead V2. The ECG finding of anterior TWI in an unselected population may not be as benign as that in athletic populations.

Funding Acknowledgement

Type of funding sources: None. Abnormal TWI: Prevalence and Yield

Evidence-Based Updates to Thrombectomy: Targets, New Techniques, and Devices

Endovascular thrombectomy (EVT) has been validated in several randomized controlled trials in recent years for its efficacy in the treatment of acute ischemic strokes (AIS) and is now the standard of care according to international guidelines. However, in about 20% of EVT procedures, recanalization is not achieved, and over 50% of patients who undergo EVT still do not have good functional outcome. In this article, we provide an extensive review of the latest evidence and developments in the field of EVT, with particular focus on the factors that improve patient outcomes. These factors include new and adjunctive techniques such as combination of direct aspiration and stent retriever, intra-arterial urokinase or 2b/3a inhibitors, rescue stenting, as well as novel devices including balloon guide catheters and the newer generations of aspiration catheters and stent retrievers. We also examined the latest notion of using first-pass effect (FPE) as the target to achieve during EVT, which has been associated with an improved functional outcome. While the field of EVT has been rapidly evolving, further research is required in specific AIS patient populations such as those with large ischemic core, late presentation beyond 24 h, posterior circulation strokes, and with distal medium vessel occlusion or tandem lesions to better assess its efficacy and safety.

Internal cerebral vein asymmetry is an independent predictor of poor functional outcome in endovascular thrombectomy

BACKGROUND

Endovascular thrombectomy (EVT) in large vessel occlusion (LVO) in anterior circulation acute ischaemic stroke (AIS) results in good functional outcomes in only approximately 60% of the patients. Internal cerebral veins (ICVs) are easily visible, with a consistent midline location, and are linked to stroke outcomes. We hypothesize that ICV asymmetry on multiphasic CT angiogram (mCTA) can be an adjunctive predictor for poor functional outcomes.

METHODS

We studied consecutive AIS patients from 2017 to 2019 with anterior circulation LVO treated with EVT regardless of intravenous thrombolysis. Asymmetrical ICV was defined as the presence of hypodensity (less opacification) on the ipsilateral occlusion side as compared with the contralateral side. The primary outcome was modified Rankin Score (mRS) score at 3 months. Secondary outcomes were good recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3), symptomatic hemorrhage, and mortality.

RESULTS

A total of 185 patients were included with a median age of 70 years (IQR 59-77); 87 patients (47%) were female. 82 patients (44.3%) achieved good functional outcomes (mRS 0-2) at 3 months. On multivariate analysis, National Institutes of Health Stroke Scale (NIHSS) (OR 1.076, 95% CI 1.015 to 1.140; p<0.013), poor collateral score (OR 0.285, 95% CI 0.162 to 0.501; p<0.001), asymmetrical ICV on the peak venous phase (OR 2.47, 95% CI 1.115 to 5.471; p<0.026), and late venous phase of the mCTA (OR 2.642, 95% CI 1.161 to 6.016; p<0.021) were independent risks factors of poor outcomes.

CONCLUSION

ICV asymmetry is a novel radiological sign which is independently associated with poor functional outcomes in EVT, even after correction for collateral circulation. Further studies are needed to validate this finding.

Comparing the efficacy and safety of direct oral anticoagulants with vitamin K antagonist in cerebral venous thrombosis

Cerebral venous thrombosis (CVT) causes significant disability and mortality. Current guidelines for CVT management support the initial use of unfractionated heparin or low molecular weight heparin followed by longer-term oral vitamin K antagonist (VKA). There has been increasing, albeit limited, evidence for the use of direct oral anticoagulants (DOAC) as an alternative to VKA. We performed a systematic review and meta-analysis of studies that compared the safety and efficacy of DOACs to VKA in treating CVT. A comprehensive literature search was carried out in Medline, Embase and Cochrane Stroke Group Trials Register using a suitable keyword/MeSH term search strategy. All studies published in English comparing outcomes of patients with CVT treated with DOAC or VKA were included. In total, 6 studies (5 observational studies and 1 randomized clinical trial) comprising 412 patients (age range 16-83 years) were analyzed. DOAC was used in 151 patients, while 261 received VKA. The follow-up period was 3-11 months. The efficacy of DOACs was comparable with VKA in terms of partial or full thrombus recanalization (RR 1.02, 95% CI 0.89-1.16) and excellent functional recovery with modified Rankin scale < 2 (RR 1.02, 95% CI 0.93-1.13). Patients treated with DOAC developed lower major bleeding events when compared to VKA, although this did not reach statistical significance (RR 0.44, 95% CI 0.12-1.59). We provide preliminary evidence to support DOAC as effective and safe alternatives to VKA in CVT treatment. We await the results of upcoming randomized trials to further support our results and validate the use of DOAC.

Evaluating the safety and efficacy of intravenous thrombolysis for acute ischemic stroke patients with a history of intracerebral hemorrhage: a systematic review and meta-analysis

Previous intracerebral hemorrhage (ICH) is labelled as a contraindication for the use of intravenous tissue plasminogen activator (IV-tPA) in acute ischemic stroke (AIS) based on expert opinion. However, there is a paucity of data available regarding the benefits and risks of IV-tPA in this population. Recent small retrospective cohort studies reporting its off-label use suggest it may be beneficial. This study aims to investigate the safety and efficacy of IV-tPA in AIS patients with previous ICH. We performed a systematic review and meta-analysis of studies reporting on IV-tPA use in AIS patients with and without previous ICH. We searched Embase, PubMed and Cochrane Library from inception to 20 April 2021. Outcomes measured included symptomatic ICH (sICH), 3-month modified Rankin Scale (mRS) score, and 3-month mortality. We included seven retrospective cohort studies comprising 5760 AIS patients who had received IV-tPA, of which 134 had previous ICH. There was no significant difference in the odds of sICH (OR 1.57, 95% CI 0.78-3.15, p = 0.21) and 3-month mRS (mRS 0-1: OR 0.78, 95% CI 0.37-1.65, p = 0.52; mRS 0-2: OR 1.07, 95% CI 0.36-3.15, p = 0.90) between patients with and without previous ICH. There was a trend towards higher 3-month mortality in patients with previous ICH (OR 1.69, 95% CI 0.98-2.91, p = 0.06), although this did not reach statistical significance. The use of IV-tPA in AIS patients with previous ICH was not associated with an increased risk of sICH or disability at 3 months. Further larger studies are needed to establish the safety and efficacy of IV-tPA use in this population.

Low Relative Valve Load is Associated With Paradoxical Low-Flow Aortic Stenosis Despite Preserved Left Ventricular Ejection Fraction and Adverse Clinical Outcomes

BACKGROUND

Paradoxical low-flow (LF) severe aortic stenosis (AS) despite preserved left ventricular (LV) ejection fraction (LVEF) has been shown to be distinct from normal-flow (NF) AS, with a poorer prognosis. Relative valve load (RVL) is a novel echocardiographic haemodynamic index based on the ratio of transaortic mean pressure gradient to the global valvulo-arterial impedance (Zva) in order to estimate the contribution of the valvular afterload to the global LV load. We aimed to determine the usefulness of RVL in LF AS versus NF AS.

METHOD

A total of 450 consecutive patients with medically managed severe AS (aortic valve area <1.0 cm²) with preserved LVEF (>50%) were studied. Patients were divided into LF (stroke volume index <35 mL/m²) or NF, and high RVL or low RVL. Baseline clinical and echocardiographic profiles, as well as clinical outcomes, were compared.

RESULTS

There were 149 (33.1%) patients with LF. Despite higher global impedance in LF (Zva 6.3±2.4 vs 3.9±0.9 mmHg/mL/m²; p<0.001) compared with NF, the RVL in LF AS was significantly lower (5.4±2.7 vs 9.8±5.1 mL/m²; p<0.001). On multivariable analysis, low RVL (≤7.51) remained independently associated with poor clinical outcomes on Cox regression (hazard ratio, 1.31; 95% confidence interval, 1.03-1.68), with 53.2% sensitivity and 70.3% specificity. This was comparable to other prognostic indices in AS. Kaplan-Meier curves demonstrated that low RVL was associated with increased mortality.

CONCLUSIONS

Increased systemic arterial afterload may be important in the pathophysiology of LF AS. Low RVL was an independent predictor of poor clinical outcomes in medically managed severe AS. There may be a greater role in the attenuation of systemic arterial afterload in AS to improve outcomes.

An Asia-Pacific study on healthcare workers' perceptions of, and willingness to receive, the COVID-19 vaccination

OBJECTIVE

In the fight against COVID-19, vaccination is vital in achieving herd immunity. Many Asian countries are starting to vaccinate frontline workers; however, expedited vaccine development has led to hesitancy among the general population. We evaluated the willingness of healthcare workers to receive the COVID-19 vaccine.

METHODS

From 12 to 21 December 2020, we recruited 1720 healthcare workers from 6 countries: China, India, Indonesia, Singapore, Vietnam and Bhutan. The self-administrated survey collected information on willingness to vaccinate, perception of COVID-19, vaccine concerns, COVID-19 risk profile, stigma, pro-socialness scale, and trust in health authorities.

RESULTS

More than 95% of the healthcare workers surveyed were willing to vaccinate. These respondents were more likely to perceive the pandemic as severe, consider the vaccine safe, have less financial concerns, less stigmatization regarding the vaccine, higher pro-socialness mindset and trust in health authorities. A high perceived pandemic risk index, low vaccine harm index and high pro-socialness index were independent predictors in multivariable analysis.

CONCLUSIONS

The majority of healthcare workers in Asia are willing to receive COVID-19 vaccination. Perceived COVID-19 susceptibility, low potential risk of vaccine harm and pro-socialness are the main drivers. These findings may help formulate vaccination strategies in other countries.

Effects of Sodium/Glucose Cotransporter 2 (SGLT2) Inhibitors on Cardiovascular and Metabolic Outcomes in Patients Without Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized-Controlled Trials

Background

Recent studies have increasingly shown that sodium‐glucose cotransporter 2 (SGLT2) inhibitors may have beneficial cardiovascular and metabolic effects in patients without diabetes mellitus. Hence, we conducted a systematic review and meta‐analysis to determine the effect of SGLT2 inhibitors on cardiovascular and metabolic outcomes in patients without diabetes mellitus.

Methods and Results

Four electronic databases (PubMed, Embase, Cochrane, and SCOPUS) were searched on August 30, 2020 for articles published from January 1, 2000 to August 30, 2020, for studies that examined the effect of SGLT2 inhibitors on cardiovascular and metabolic outcomes in patients without diabetes mellitus. A random‐effects pairwise meta‐analysis model was used to summarize the studies. A total of 8 randomized‐controlled trials were included with a combined cohort of 5233 patients. In patients without diabetes mellitus, those with heart failure treated with SGLT2 inhibitors had a 20% relative risk reduction in cardiovascular deaths and heart failure hospitalizations, compared with those who were not treated (risk ratio, 0.78; P<0.001). We additionally found that treatment with SGLT2 inhibitors improved multiple metabolic indices. Patients on SGLT2 inhibitors had a reduction in body weight of −1.21 kg (P<0.001), body mass index of −0.47 kg/m² (P<0.001), systolic blood pressure of −1.90 mm Hg (P=0.04), and fasting plasma glucose of −0.38 mmol/L (P=0.05), compared with those without. There were no between‐group differences in NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) levels, waist circumference, diastolic blood pressure, glycated hemoglobin, low‐density lipoprotein cholesterol levels, and estimated glomerular filtration rates. Across our combined cohort of 5233 patients, hypoglycemia was reported in 22 patients.

Conclusions

SGLT2 inhibitors improve cardiovascular outcomes in patients without diabetes mellitus with heart failure. In patients without diabetes mellitus, SGLT2 inhibitors showed positive metabolic outcomes in weight and blood pressure control.

Intra-Arterial Adjunctive Medications for Acute Ischemic Stroke During Mechanical Thrombectomy: A Meta-Analysis

BACKGROUND AND PURPOSE

In patients with acute ischemic stroke with large vessel occlusion, the role of intra-arterial adjunctive medications (IAMs), such as urokinase, tPA (tissue-type plasminogen activator), or glycoprotein IIb/IIIa inhibitors, during mechanical thrombectomy (MT) has not been clearly established. We aim to evaluate the efficacy and safety of concomitant or rescue IAM for acute ischemic stroke with large vessel occlusion patients undergoing MT.

METHODS

We searched Medline, Embase, and Cochrane Stroke Group Trials Register databases from inception until March 13, 2020. We analyzed all studies with patients diagnosed with acute ischemic stroke with large vessel occlusion in the anterior or posterior circulation that provided data for the two treatment arms, (1) MT+IAM and (2) MT only, and also reported on at least one of the following efficacy outcomes, recanalization and 90-day modified Rankin Scale, or safety outcomes, symptomatic intracranial hemorrhage and 90-day mortality. Data were collated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Sixteen nonrandomized observational studies with a total of 4581 patients were analyzed. MT only was performed in 3233 (70.6%) patients, while 1348 (29.4%) patients were treated with both MT and IAM. As compared with patients treated with MT alone, patients treated with combination therapy (MT+IAM) had a higher likelihood of achieving good functional outcome (risk ratio, 1.13 [95% CI, 1.03-1.24]) and a lower risk of 90-day mortality (risk ratio, 0.82 [95% CI, 0.72-0.94]). There was no significant difference in successful recanalization (risk ratio, 1.02 [95% CI, 0.99-1.06]) and symptomatic intracranial hemorrhage between the two groups (risk ratio, 1.13 [95% CI, 0.87-1.46]).

CONCLUSIONS

In acute ischemic stroke with large vessel occlusion, the use of IAM together with MT may achieve better functional outcomes and lower mortality rates. Randomized controlled trials are warranted to establish the safety and efficacy of IAM as adjunctive treatment to MT.

Burnout and Associated Factors Among Health Care Workers in Singapore During the COVID-19 Pandemic

OBJECTIVES

The strain on health care systems due to the COVID-19 pandemic has led to increased psychological distress among health care workers (HCWs). As this global crisis continues with little signs of abatement, we examine burnout and associated factors among HCWs.

DESIGN

Cross-sectional survey study.

SETTING AND PARTICIPANTS

Doctors, nurses, allied health professionals, administrative, and support staff in 4 public hospitals and 1 primary care service in Singapore 3 months after COVID-19 was declared a global pandemic.

METHODS

Study questionnaire captured demographic and workplace environment information and comprised 3 validated instruments, namely the Oldenburg Burnout Inventory (OLBI), Safety Attitudes Questionnaire (SAQ), and Hospital Anxiety and Depression Scale (HADS). Multivariate mixed model regression analyses were used to evaluate independent associations of mean OLBI-Disengagement and -Exhaustion scores. Further subgroup analysis was performed among redeployed HCWs.

RESULTS

Among 11,286 invited HCWs, 3075 valid responses were received, giving an overall response rate of 27.2%. Mean OLBI scores were 2.38 and 2.50 for Disengagement and Exhaustion, respectively. Burnout thresholds in Disengagement and Exhaustion were met by 79.7% and 75.3% of respondents, respectively. On multivariate regression analysis, Chinese or Malay ethnicity, HADS anxiety or depression scores ≥8, shifts lasting ≥8 hours, and being redeployed were significantly associated with higher OLBI mean scores, whereas high SAQ scores were significantly associated with lower scores. Among redeployed HCWs, those redeployed to high-risk areas in a different facility (offsite) had lower burnout scores than those redeployed within their own work facility (onsite). A higher proportion of HCWs redeployed offsite assessed their training to be good or better compared with those redeployed onsite.

CONCLUSIONS AND IMPLICATIONS

Every level of the health care workforce is susceptible to high levels of burnout during this pandemic. Modifiable workplace factors include adequate training, avoiding prolonged shifts ≥8 hours, and promoting safe working environments. Mitigating strategies should target every level of the health care workforce, including frontline and nonfrontline staff. Addressing and ameliorating burnout among HCWs should be a key priority for the sustainment of efforts to care for patients in the face of a prolonged pandemic.

Left ventricular systolic dysfunction is associated with poor functional outcomes after endovascular thrombectomy

BACKGROUND

Endovascular thrombectomy (ET) has transformed acute ischemic stroke (AIS) therapy in patients with large vessel occlusion (LVO). Left ventricular systolic dysfunction (LVSD) decreases global cerebral blood flow and predisposes to hypoperfusion. We evaluated the relationship between LVSD, as measured by LV ejection fraction (LVEF), and clinical outcomes in patients with anterior cerebral circulation LVO who underwent ET.

METHODS

This multicenter retrospective cohort study examined anterior circulation LVO AIS patients from six international stroke centers. LVSD was measured by assessment of the echocardiographic LVEF using Simpson's biplane method of discs according to international guidelines. LVSD was defined as LVEF <50%. The primary outcome was defined as a good functional outcome using a modified Rankin Scale (mRS) of 0-2 at 3 months.

RESULTS

We included 440 AIS patients with LVO who underwent ET. On multivariate analyses, pre-existing diabetes mellitus (OR 2.05, 95% CI 1.24 to 3.39;p=0.005), unsuccessful reperfusion (Treatment in Cerebral Infarction (TICI) grade 0-2a) status (OR 4.21, 95% CI 2.04 to 8.66; p<0.001) and LVSD (OR 2.08, 95% CI 1.18 to 3.68; p=0.011) were independent predictors of poor functional outcomes at 3 months. On ordinal (shift) analyses, LVSD was associated with an unfavorable shift in the mRS outcomes (OR 2.32, 95% CI 1.52 to 3.53; p<0.001) after adjusting for age and ischemic heart disease.

CONCLUSION

Anterior circulation LVO AIS patients with LVSD have poorer outcomes after ET, suggesting the need to consider cardiac factors for ET, the degree of monitoring and prognostication post-procedure.