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Chen Z, Lin W, Zhang F, Cao W. Risk Factors and Prognosis Analysis of Upper Gastrointestinal Bleeding in Patients With Acute Severe Cerebral Stroke. J Clin Gastroenterol 2024; 58:440-446. [PMID: 37341702 PMCID: PMC10994183 DOI: 10.1097/mcg.0000000000001877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/22/2023] [Indexed: 06/22/2023]
Abstract
GOALS We aim to explore the relationship between the use of proton pump inhibitors (PPIs) and upper gastrointestinal bleeding (UGIB). We develop a nomogram model to predict mortality in critically ill stroke patients. STUDY This is a retrospective study based on the MIMIC IV database. We extracted clinical information including demographic data, comorbidities, and laboratory indicators. Univariate and multivariable logistic regressions were used to assess and identify risk factors for the occurrence of UGIB and for the in-hospital mortality of critically ill stroke patients. The resulting model was used to construct a nomogram for predicting in-hospital mortality. RESULTS Five thousand seven hundred sixteen patients from the MIMIC-IV database were included in our analysis. UGIB occurred in 109 patients (1.9%), whereas the PPI use rate was as high as 60.6%. Chronic liver disease, sepsis, shock, anemia, and increased level of urea nitrogen were independent risk factors for the occurrence of UGIB in severe stroke patients. We identified age, heart failure, shock, coagulopathy, mechanical ventilation, continuous renal replacement therapy, antiplatelet drugs, anticoagulation, simplified acute physiology score-II, and Glasgow coma score as independent risk factors for in-hospital mortality in severe stroke patients. The C-index for the final nomograms was 0.852 (95% confidence interval: 0.840, 0.864). CONCLUSIONS We found that the overall rate of UGIB in severe stroke patients is low, whereas the rate of PPI usage is high. In our study, PPI was not identified as a risk factor for the occurrence of UGIB and UGIB was not associated with all-cause mortality. More clinical trials are needed to evaluate the benefits of using PPI in critically ill stroke patients.
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Hua X, Liu M, Wu S. Definition, prediction, prevention and management of patients with severe ischemic stroke and large infarction. Chin Med J (Engl) 2023; 136:2912-2922. [PMID: 38030579 PMCID: PMC10752492 DOI: 10.1097/cm9.0000000000002885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Indexed: 12/01/2023] Open
Abstract
ABSTRACT Severe ischemic stroke carries a high rate of disability and death. The severity of stroke is often assessed by the degree of neurological deficits or the extent of brain infarct, defined as severe stroke and large infarction, respectively. Critically severe stroke is a life-threatening condition that requires neurocritical care or neurosurgical intervention, which includes stroke with malignant brain edema, a leading cause of death during the acute phase, and stroke with severe complications of other vital systems. Early prediction of high-risk patients with critically severe stroke would inform early prevention and treatment to interrupt the malignant course to fatal status. Selected patients with severe stroke could benefit from intravenous thrombolysis and endovascular treatment in improving functional outcome. There is insufficient evidence to inform dual antiplatelet therapy and the timing of anticoagulation initiation after severe stroke. Decompressive hemicraniectomy (DHC) <48 h improves survival in patients aged <60 years with large hemispheric infarction. Studies are ongoing to provide evidence to inform more precise prediction of malignant brain edema, optimal indications for acute reperfusion therapies and neurosurgery, and the individualized management of complications and secondary prevention. We present an evidence-based review for severe ischemic stroke, with the aims of proposing operational definitions, emphasizing the importance of early prediction and prevention of the evolution to critically severe status, summarizing specialized treatment for severe stroke, and proposing directions for future research.
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Affiliation(s)
- Xing Hua
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Lim H, Madhavan S. Non-paretic leg movements can facilitate cortical drive to the paretic leg in individuals post stroke with severe motor impairment: Implications for motor priming. Eur J Neurosci 2023; 58:2853-2867. [PMID: 37354080 PMCID: PMC10530620 DOI: 10.1111/ejn.16069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/07/2023] [Accepted: 06/10/2023] [Indexed: 06/26/2023]
Abstract
Cross-education, a phenomenon where unilateral strength (or skill) training enhances strength (or skill) in the contralateral untrained limb, has been well studied in able-bodied individuals. Cross-education effect accompanies bilateral changes of corticomotor activity in the motor cortex (M1). Recent reports demonstrated greater cross-education effect in stroke survivors compared to healthy individuals, however, corticomotor responses to cross-education in stroke remains unclear. This study aimed to determine the effects of non-paretic leg movements on corticomotor excitability (CME) and reaction time of the paretic leg in severely impaired stroke survivors. Seventeen post stroke individuals with severe leg motor impairment (Fugl-Meyer lower extremity score less than 21 and absence of motor evoked potential in the paretic leg) performed three 20-min motor trainings using their non-paretic ankle: skill (targeted dynamic movements), strength (isometric resistance) and sham (sub-threshold electrical nerve stimulation). During training, verbal instructions were given to the participants to limit their movement to the non-paretic leg and this was confirmed with visual observation of the paretic leg. Transcranial magnetic stimulation measured CME of the contralateral pathways from the non-lesioned M1 to the non-paretic tibialis anterior (TA) muscle, ipsilateral pathways to the paretic TA and transcallosal inhibition (TCI) from the non-lesioned to lesioned M1. Paretic ankle reaction time was measured using a reaction time paradigm. All outcomes were measured before, immediately post, 30-min post and 60-min post priming. CME of the non-paretic TA increased after skill (.08 ± .10 mV) and strength (.06 ± .05 mV) training (p < .01). Ipsilateral CME of the paretic TA (.02 ± .01 mV) and TCI (.01 ± .01 s, ipsilateral silent period; more inhibition to the lesioned M1) increased after skill (p < .05) but not strength training. Reaction time of the paretic ankle improved after skill and strength training (-.11 ± .2 and -.13 ± .20 s, respectively; p < .05) and was sustained at 60 min. No changes were observed during the sham condition. Our findings may inform future studies for using non-paretic leg movements as a priming modality, especially for those who are contraindicated to other priming paradigms (e.g., brain stimulation) or unable to perform paretic leg movements. Conclusion: Non-paretic leg movements can be used as a priming modality, especially for those who are contraindicated to other priming paradigms (e.g., brain stimulation) or unable to perform paretic leg movements.
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Affiliation(s)
- Hyosok Lim
- Brain Plasticity Laboratory, Department of Physical Therapy, University of Illinois at Chicago, Chicago, IL, USA
- Graduate Program in Rehabilitation Sciences, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Sangeetha Madhavan
- Brain Plasticity Laboratory, Department of Physical Therapy, University of Illinois at Chicago, Chicago, IL, USA
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Pana TA, Craigen F, Mohamed MO, Mamas MA, Myint PK. In-hospital outcomes of acute ischaemic stroke patients with atrial septal defect. A national inpatient sample study. Am J Cardiovasc Dis 2023; 13:183-191. [PMID: 37469530 PMCID: PMC10352813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/15/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND AND AIMS Atrial septal defects (ASD) are a well-recognised risk factor for acute ischaemic stroke (AIS). We aimed to delineate the relationship between ASD and in-hospital AIS outcomes (mortality, severe stroke (National Institutes of Health Stroke Scale (NIHSS) > 15), prolonged hospitalisation > 4 days and routine home discharge) in contemporary practice using data from the United States National Inpatient Sample. METHODS NIS admissions with a primary diagnosis of AIS between 2016-2018 were extracted. The NIHSS variable had 75% missing data, which were imputed using multiple imputations by chained equations. The relationship between ASD and the main outcomes was modelled using multivariable logistic regressions, adjusting for age, sex, comorbidities, stroke severity and revascularisation therapies. RESULTS 245,859 records representative of 1,229,295 AIS admissions were included, 35,840 (2.91%) of whom had ASD. ASD patients were younger (median age 63 years versus 72 years) and less likely to have traditional cardiovascular risk factors than their counterparts without ASD. ASD was independently associated with 58% lower odds of in-hospital mortality (hazard ratio (95% confidence interval) = 0.42 (0.33-0.54)), 18% lower odds of severe stroke (0.82 (0.71-0.94)), 20% higher odds of routine home discharge (1.20 (1.14-1.28)) and 28% higher odds of prolonged hospitalisation (1.28 (1.21-1.35)). CONCLUSIONS ASD was associated with better in-hospital outcomes, which were likely driven by younger age, lower prevalence of traditional cardiovascular risk factors, and lower stroke severity. Further research is warranted to clarify the ASD anatomical characteristics which are most strongly associated with these associations.
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Affiliation(s)
- Tiberiu Alexandru Pana
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele UniversityStoke-on-Trent, Keele, United Kingdom
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, University of AberdeenAberdeen, United Kingdom
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of AberdeenAberdeen, United Kingdom
| | - Fiona Craigen
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele UniversityStoke-on-Trent, Keele, United Kingdom
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, University of AberdeenAberdeen, United Kingdom
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of AberdeenAberdeen, United Kingdom
| | - Mohamed O Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele UniversityStoke-on-Trent, Keele, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele UniversityStoke-on-Trent, Keele, United Kingdom
| | - Phyo Kyaw Myint
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, University of AberdeenAberdeen, United Kingdom
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of AberdeenAberdeen, United Kingdom
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Chen Y, Yang X, Zhu Y, Zhang X, Ni J, Li Y. Malnutrition Defined by Geriatric Nutritional Risk Index Predicts Outcomes in Severe Stroke Patients: A Propensity Score-Matched Analysis. Nutrients 2022; 14:nu14224786. [PMID: 36432473 PMCID: PMC9696179 DOI: 10.3390/nu14224786] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/03/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Malnutrition’s prognostic impact in patients with severe stroke requiring ICU admission is not well known. This study aimed to assess the nutritional status of severe stroke patients using the geriatric nutritional risk index (GNRI) and examine the association of GNRI with mortality in that population. Methods: We identified 1145 severe stroke patients requiring ICU admission from the Medical Information Mart for Intensive Care (MIMIC-III) database and divided them into low GNRI (≤98) or high GNRI (>98) groups. We used a propensity score matching (PSM) method to reduce confounding. Cox proportional hazards regression and restricted cubic splines were used to elucidate the association between GNRI and mortality. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated. Results: A total of 397 (35%) patients were in the low GNRI group (at risk of malnutrition). After PSM, patients in the low GNRI group still suffered higher mortality compared with the high GNRI group at 28 days (27.9 vs. 20.8%), 90 days (35.5 vs. 25.7%), and 1 year (43.4 vs. 30.9%) (p < 0.05). A low GNRI was significantly associated with an increased mortality (HR: 1.38, 95% CI 1.03−1.86 in 28 days; HR: 1.45, 95% CI 1.11−1.89 in 90 days; HR: 1.51, 95% CI 1.19−1.92 in 1 year). Sensitivity analyses yielded consistent results. Restricted cubic splines showed a progressively decreasing risk of mortality with increasing GNRI scores up to 110, approximately. Conclusion: Severe stroke patients with malnutrition experienced an increased risk of death compared to those without malnutrition. GNRI, as a simple and practical nutritional screening tool, can be used as a routine approach to the nutritional status of stroke patients.
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Affiliation(s)
- Ying Chen
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510000, China
| | - Xinguang Yang
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510000, China
| | - Yingying Zhu
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510000, China
- Division of Clinical Research Design, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510000, China
| | - Xiaoni Zhang
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510000, China
| | - Jingxian Ni
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510000, China
| | - Yi Li
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510000, China
- Correspondence: ; Tel.: +86-020-3407-1576
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Qin L, Zhang XX, Jin X, Cui CH, Tang CZ. The Effect of Acupuncture on Enteral Nutrition and Gastrointestinal Dynamics in Patients Who Have Suffered a Severe Stroke. Curr Neurovasc Res 2022; 19:275-281. [PMID: 35996236 DOI: 10.2174/1567202619666220822123023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/10/2022] [Accepted: 07/19/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aimed to explore and analyze the effect of acupuncture on improving the enteral nutrition level and gastrointestinal dynamics in patients who had suffered a severe stroke. METHODS A total of 122 patients who experienced a severe stroke who were treated in the intensive care unit of the Affiliated Hospital of Hebei University (China) between September 2021 and March 2022 were randomly divided into two groups as follows: 1) the observation group, the participants of which received acupuncture combined with early enteral nutrition (61 cases); 2) the control group, the participants of which received early enteral nutrition (61 cases). Following treatment, the hemoglobin, neutrophil count, blood glucose, albumin, pre-albumin, immediate postprandial antral area, antral contraction frequency (at 2 min), and antral motility index on days 1 and 7 of treatment were compared between the two groups. RESULTS The total clinical effective rate was 96.72% in the observation group and 77.05% in the control group. The curative effect comparison between the two groups after seven days of treatment showed a lower probability of gastrointestinal bleeding, faster recovery of gastrointestinal motility, and a higher level of nutrient absorption in the observation group. Serum albumin, pre-albumin, hemoglobin, total lymphocyte count, immediate postprandial maximum (max) and minimum (mix) area of the gastric antrum, antral contraction frequency (at 2 min), and antral motility index were higher in the observation group than in the control group (P < 0.05). The difference in blood glucose levels between the two groups was not statistically significant (P > 0.05). CONCLUSION Acupuncture improved the enteral nutrition status of patients who had suffered a severe stroke and promoted gastrointestinal motility. The combination of acupuncture and early enteral nutrition could reduce damage to the gastrointestinal mucosal barrier caused by stress, changes in metabolism, and improved gastrointestinal function.
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Affiliation(s)
- Liang Qin
- Acupuncture Rehabilitation Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, Guangzhou, 510006, China.,Department of Rehabilitation Medicine, Affiliated Hospital of Hebei University, Baoding, 071000, China
| | - Xin-Xin Zhang
- Department of Emergency Medicine, Affiliated Hospital of Hebei University, Baoding, 071000, China
| | - Xin Jin
- Department of Neurology, Intensive Care Unit of Affiliated Hospital of Hebei University, Baoding, 071000, China
| | - Cai-Hong Cui
- Department of Rehabilitation Medicine, Affiliated Hospital of Hebei University, Baoding, 071000, China
| | - Chun-Zhi Tang
- Acupuncture Rehabilitation Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, Guangzhou, 510006, China
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Riesinger R, Altmann K, Lorenzl S. Involvement of Specialist Palliative Care in a Stroke Unit in Austria-Challenges for Families and Stroke Teams. Front Neurol 2021; 12:683624. [PMID: 34630274 PMCID: PMC8492896 DOI: 10.3389/fneur.2021.683624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/09/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose: Severe stroke poses vast challenges. Appropriate goals of care according to individual preferences and values have to be developed under time restrictions—often impeded by limited ability to communicate and the need for decisions by surrogates. The aim of our study was to explore the decision-making process and the involvement of specialist palliative care in the acute phase of severe stroke. Methods: Twenty patients suffering from severe ischemic stroke treated in an Austrian acute inpatient stroke unit were included in a prospective study. Their families were interviewed with a questionnaire (FS-ICU 24), which covered satisfaction with care and decision-making. With a second questionnaire, decision-making processes within the stroke team were investigated. Results: A palliative approach and early integration of specialist palliative care in severe ischemic stroke results in individualized therapeutic goals, including withholding therapeutic or life-sustaining measures, especially in patients with pre-existing illness. Conclusions: Family members benefit from understandable and consistent information, emotional support, and a professional team identifying their needs. Stroke unit professionals need skills as well as knowledge and strategies in order to make decisions and provide treatment at the end-of-life, when there may be ethical or legal issues. Close cooperation with specialist palliative care services supports both treatment teams and families with communication and decision-making for patients with severe ischemic stroke.
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Affiliation(s)
- Renate Riesinger
- Department of Palliative Care, Hospital Barmherzige Schwestern, Ried im Innkreis, Austria
| | - Klaus Altmann
- Department of Neurology, Hospital Barmherzige Schwestern, Ried im Innkreis, Austria
| | - Stefan Lorenzl
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria.,Ludwig-Maximilians-University, Munich, Germany.,Department of Neurology, Klinikum Agatharied, Hausham, Germany
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Khazaal O, Rothstein A, Husain MR, Broderick M, Cristancho D, Reyes-Esteves S, Khan F, Favilla CG, Messé SR, Mullen MT. Dual-Antiplatelet Therapy May Not Be Associated With an Increased Risk of In-hospital Bleeding in Patients With Moderate or Severe Ischemic Stroke. Front Neurol 2021; 12:728111. [PMID: 34616353 PMCID: PMC8488084 DOI: 10.3389/fneur.2021.728111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/20/2021] [Indexed: 11/30/2022] Open
Abstract
Background and Purpose: Dual antiplatelet therapy (DAPT), compared to single antiplatelet therapy (SAPT), lowers the risk of stroke or death early after TIA and minor ischemic stroke. Prior trials excluded moderate to severe strokes, due to a potential increased risk of bleeding. We aimed to compare in-hospital bleeding rates in SAPT and DAPT patients with moderate or severe stroke (defined by NIHSS ≥4). Methods: We performed a retrospective cohort study of ischemic stroke over a 2-year period with admission NIHSS ≥4. The primary outcome was symptomatic intracranial hemorrhage (ICH) with any change in NIHSS. Secondary outcomes included systemic bleeding and major bleeding, a composite of serious systemic bleeding and symptomatic ICH. We performed analyses stratified by stroke severity (NIHSS 4–7 vs. 8+) and by preceding use of tPA and/or thrombectomy. Univariate followed by multivariate logistic regression evaluated whether DAPT was independently associated with bleeding. Results: Of 377 patients who met our inclusion criteria, 148 received DAPT (39%). Symptomatic ICH was less common with DAPT compared to SAPT (0.7 vs. 6.4%, p < 0.01), as was the composite of major bleeding (2.1 vs. 7.6%, p = 0.03). Symptomatic ICH was numerically less frequent in the DAPT group, but not statistically significant, when stratified by stroke severity (NIHSS 4–7: 0 vs. 5.9%, p = 0.06; NIHSS 8+: 1.5 vs. 6.6%, p = 0.18) and by treatment with tPA and/or thrombectomy (Yes: 2.6 vs. 9.1%, p = 0.30; No: 0 vs. 2.9%, p = 0.25). DAPT was not associated with major bleeding in either the univariate or the multivariate regression. Conclusions: In this single center cohort, symptomatic ICH and the composite of serious systemic bleeding and symptomatic ICH was rare in patients on DAPT. Relative to single antiplatelet therapy DAPT was not associated with an increased risk of in-hospital bleeding in patients with moderate and severe ischemic stroke.
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Affiliation(s)
- Ossama Khazaal
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Aaron Rothstein
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Muhammad R Husain
- Department of Neurology, Camden Clark Medical Center/WVU Medicine, Parkersburg, WV, United States
| | - Matthew Broderick
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Daniel Cristancho
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Sahily Reyes-Esteves
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Farhan Khan
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Christopher G Favilla
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Steven R Messé
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael T Mullen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
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Liu X, Zhang Y, Chu J, Zheng J, Cheng X, Li X, Long J. Effect of probiotics on the nutritional status of severe stroke patients with nasal feeding that receive enteral nutrition: A protocol for systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e25657. [PMID: 33907128 PMCID: PMC8084017 DOI: 10.1097/md.0000000000025657] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/30/2021] [Accepted: 04/03/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Malnutrition is commonly observed after stroke and is closely associated with poor clinical outcomes. So, early nutrition support is particularly crucial for severe stroke patients. However, a significant number of critically ill patients are intolerant to enteral nutrition (EN). Probiotics have been widely used in malnutrition by various diseases and have a low incidence of enteral intolerance. So, we aim to elucidate the efficacy of probiotics in EN in improving the nutritional status and clinical prognosis of severe stroke patients with nasal feeding. METHOD Embase, PubMed, Sinomed, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wanfang database, and Vip Journal Integration Platform were searched from inception to March 31, 2021. Randomized controlled trials that applied probiotics in patients with severe stroke were included. The data were extracted and the risk of bias was assessed independently by 2 evaluators. RESULTS Twenty-four studies comprising 2003 participants of randomized controlled trials were included. The result of pooled analyses showed that probiotics in EN were associated with better outcomes than EN alone on Glasgow Coma Scale score (mean difference [MD] = 1.03, 95% confidence intervals [CI]: 0.78-1.27; P < .00001), infection events (odds ratio [OR] = 0.25, 95% CI: 0.15-0.43; P < .00001), rate of intestinal flora dysbiosis (OR = 0.24, 95% CI: 0.12-0.48; P < .0001), gastrointestinal complications (OR = 0.25, 95% CI: 0.16-0.37, P < .00001), time to reach target nutrition (MD = -1.80, 95% CI: -2.42 to 1.18, P < .00001), prealbumin content (MD = 25.83, 95% CI: 13.68-37.99, P < .0001). CONCLUSION Our results demonstrated that probiotics supplementation might be an effective intervention for improving the clinical prognosis in severe stroke patients with nasal feeding, but no significant effect on increasing muscle circumference.
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Affiliation(s)
| | | | | | | | | | - Xinmin Li
- School of Basic Medical Science, Henan University of Chinese Medicine, Zhengzhou, China
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10
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Zhao J, Yuan F, Fu F, Liu Y, Xue C, Wang K, Yuan X, Li D, Liu Q, Zhang W, Jia Y, He J, Zhou J, Wang X, Lv H, Huo K, Li Z, Zhang B, Wang C, Li L, Li H, Yang F, Jiang W. Blood pressure variability and outcome in acute severe stroke: A post hoc analysis of CHASE-A randomized controlled trial. J Clin Hypertens (Greenwich) 2020; 23:96-102. [PMID: 33226186 PMCID: PMC8029725 DOI: 10.1111/jch.14090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022]
Abstract
The influence of blood pressure variability (BPV) on outcomes in patients with severe stroke is still largely unsettled. Using the data of CHASE trial, the authors calculated the BPV during the acute phase and subacute phase of severe stroke, respectively. The primary outcome was to investigate the relationship between BPV and 90‐day modified Rankin scale (mRS) ≥ 3. The BPV was assessed by eight measurements including standard deviation (SD), mean, maximum, minimum, coefficient of variation (CV), successive variation (SV), functional successive variation (FSV), and average real variability (ARV). Then, the SD of SBP was divided into quintiles and compared the quintile using logistic regression in three models. The acute phase included 442 patients, and the subacute phase included 390 patients. After adjustment, six measurements of BPV during the subacute phase rather than acute phase were strongly correlated with outcomes including minimum (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.69‐0.99, p = .037), SD (OR: 1.10, 95% CI: 1.03‐1.17, p = .007), CV (OR: 1.12, 95% CI: 1.03‐1.23, p = .012), ARV (OR: 1.13, 95% CI: 1.05‐1.20, p < .001), SV (OR: 1.09, 95% CI: 1.04‐1.15, p = .001), and FSV (OR: 1.12, 95% CI: 1.05‐1.19, p = .001). In the logistic regression, the highest fifth of SD of SBP predicted poor outcome in all three models. In conclusion, the increased BPV was strongly correlated with poor outcomes in the subacute phase of severe stroke, and the magnitude of association was progressively increased when the SD of BP was above 12.
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Affiliation(s)
- Jingjing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yuan
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Feng Fu
- Department of Neurology, 215 Hospital of Shaanxi NI, Xianyang, China
| | - Yi Liu
- Department of Neurology, Ankang Central Hospital, Ankang, China
| | - Changhu Xue
- Department of Neurology, Xianyang Central Hospital, Xianyang, China
| | - Kangjun Wang
- Department of Neurology, Hanzhong Central Hospital, Hanzhong, China
| | - Xiangjun Yuan
- Department of Neurology, Weinan Central Hospital, Weinan, China
| | - Dingan Li
- Department of Neurology, Hanzhong Central Hospital, Hanzhong, China
| | - Qiuwu Liu
- Department of Neurology, Xi'an 141 Hospital, Xi'an, China
| | - Wei Zhang
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Yi Jia
- Department of Neurology, Xi'an Gaoxin Hospital, Xi'an, China
| | - Jianbo He
- Department of Neurology, Xi'an XD Group Hospital, Xi'an, China
| | - Jun Zhou
- Department of Neurology, Shangluo Central Hospital, Shangluo, China
| | - Xiaocheng Wang
- Department of Neurology, Yulin No. 2 Central Hospital, Yulin, China
| | - Hua Lv
- Department of Neurology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Kang Huo
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhuanhui Li
- Department of Neurology, 521 Hospital of NORINCO Group, Xi'an, China
| | - Bei Zhang
- Department of Neurology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, China
| | - Chengkai Wang
- Department of Neurology, Tongchuan People's Hospital, Tongchuan, China
| | - Li Li
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, China
| | - Hongzeng Li
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, China
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11
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Yuan F, Yang F, Zhao J, Fu F, Liu Y, Xue C, Wang K, Yuan X, Li D, Liu Q, Zhang W, Jia Y, He J, Zhou J, Wang X, Lv H, Huo K, Li Z, Zhang B, Wang C, Li L, Li H, Jiang W. Controlling Hypertension After Severe Cerebrovascular Event (CHASE): A randomized, multicenter, controlled study. Int J Stroke 2020; 16:456-465. [PMID: 32525464 DOI: 10.1177/1747493020932784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The optimal blood pressure lowering target in the acute phase of severe stroke is uncertain. Our aim was to compare the efficacy and safety of individualized blood pressure lowering with standard blood pressure lowering in severe stroke. METHODS Five-hundred consecutive patients with acute severe stroke and elevated BP were recruited from 26 Chinese hospitals. Eligible patients were randomized into an individualized blood pressure lowering group (with 10-15% reduction in systolic blood pressure from admission level or standard blood pressure lowering group (with a target SBP of <200 mm Hg in acute ischemic stroke and <180 mm Hg in intracerebral hemorrhage). The primary outcome was the proportion of patients with a poor functional outcome at day 90 of enrolment. RESULTS Of 483 participants included in the analysis, 242 received individualized blood pressure lowering treatment and 241 received standard treatment. The primary outcome event was observed in 71.1% of the participants in the individualized treatment group and in 73.4% of the standard treatment group (odds ratio with individualized treatment for primary outcome, 0.75; 95% confidence interval, 0.47 to 1.19; p = 0.222). The rates of serious adverse events in the two groups were similar (27.7% vs. 28.2%). CONCLUSIONS In patients with acute severe stoke, individualized blood pressure lowering treatment did not significantly reduce the rate of three-month death or dependence. TRIAL REGISTRATION Clinicaltrials.gov, NCT02982655. Registered in 5 December 2016, https://clinicaltrials.gov/ct2/show/NCT02982655.
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Affiliation(s)
- Fang Yuan
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jingjing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Feng Fu
- Department of Neurology, Shaanxi 215 Hospital, Xianyang, China
| | - Yi Liu
- Department of Neurology, Ankang Central Hospital, Ankang, China
| | - Changhu Xue
- Department of Neurology, Xianyang Central Hospital, Xianyang, China
| | - Kangjun Wang
- Department of Neurology, Hanzhong Central Hospital, Hanzhong, China
| | - Xiangjun Yuan
- Department of Neurology, Weinan Central Hospital, Weinan, China
| | - Dingan Li
- Department of Neurology, Hanzhong Central Hospital, Hanzhong, China
| | - Qiuwu Liu
- Department of Neurology, Xi'an 141 Hospital, Xi'an, China
| | - Wei Zhang
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Yi Jia
- Department of Neurology, Xi'an Gaoxin Hospital, Xi'an, China
| | - Jianbo He
- Department of Neurology, Xi'an XD Group Hospital, Xi'an, China
| | - Jun Zhou
- Department of Neurology, Shangluo Central Hospital, Shangluo, China
| | - Xiaocheng Wang
- Department of Neurology, Yulin No.2 Central Hospital, Yulin, China
| | - Hua Lv
- Department of Neurology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Kang Huo
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhuanhui Li
- Department of Neurology, 521 Hospital of NORINCO Group, China
| | - Bei Zhang
- Department of Neurology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, China
| | - Chengkai Wang
- Department of Neurology, Tongchuan People's Hospital, Tongchuan, China
| | - Li Li
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, China
| | - Hongzeng Li
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, China
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12
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Frey I, De Boer ME, Dronkert L, Pols AJ, Visser MC, Hertogh CMPM, Depla MFIA. Between Choice, Necessity, and Comfort: Deciding on Tube Feeding in the Acute Phase After a Severe Stroke. Qual Health Res 2020; 30:1114-1124. [PMID: 32418501 PMCID: PMC7322925 DOI: 10.1177/1049732320911370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
This is an ethnographic study of decision-making concerning tube feeding in the acute phase after a severe stroke. It is based on 6 months of ethnographic research in three stroke units in the Netherlands, where the decision-making on life-sustaining treatment was studied in 16 cases of severe stroke patients. Data were collected through participant observation and interviews. For this article, the analysis was narrowed down to the decision whether or not the patient should receive tube feeding. The data on tube feeding were assembled and coded according to different modes of dealing with this decision in clinical practice, which we refer to as "repertoires." We discerned three different repertoires: choice, necessity, and comfort. Each repertoire structures clinical practice differently: It implies distinctive ethical imperatives, central concerns, sources of information, and temporalities. We hope our findings can improve decision-making by uncovering its underlying logics in clinical practice.
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Affiliation(s)
- Isabel Frey
- Vrije Universiteit Amsterdam, Amsterdam,
The Netherlands
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13
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Dharmasaroja PA, Muengtaweepongsa S. Outcomes of patients with large middle cerebral artery infarct treated with and without intravenous thrombolysis. J Neurosci Rural Pract 2016; 7:36-9. [PMID: 26933341 PMCID: PMC4750336 DOI: 10.4103/0976-3147.172149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Many thrombolytic studies showed that severe stroke was associated with death and having symptomatic intracerebral hemorrhage and inversely related to a favorable outcome. Aims: The purpose of this study is to compare the outcomes of patients with acute large middle cerebral artery (MCA) infarction with and without intravenous recombinant-tissue-plasminogen activator (rtPA) treatment. Methods: Patients with acute, large MCA infarction (National Institute of Health Stroke Scale [NIHSS] >15) who were treated during 2011–2014 were studied. The demographic data and the outcomes were compared between patients with and without intravenous rtPA treatment. Results: Two hundred and forty patients were included. Mean NIHSS score was 20. One hundred and twenty patients were treated with intravenous rtPA treatment. The patients with rtPA treatment had higher rates of favorable outcomes (39% vs. 17%, P < 0.001) and lower mortality rate (16% vs. 51%, P < 0.001). There was no significant difference in the occurrence of symptomatic intracerebral hemorrhage (6% vs. 4%, P = 0.715). Conclusions: The study showed the benefit and safety of intravenous rtPA treatment in patients with acute large MCA infarct.
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Affiliation(s)
- Pornpatr A Dharmasaroja
- Department of Internal Medicine, Stroke and Neurodegenerative Diseases Research Unit, Faculty of Medicine, Thammasat University, Pathumthani 12120, Thailand
| | - Sombat Muengtaweepongsa
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani 12120, Thailand
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14
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Katz BS, McMullan JT, Sucharew H, Adeoye O, Broderick JP. Design and validation of a prehospital scale to predict stroke severity: Cincinnati Prehospital Stroke Severity Scale. Stroke 2015; 46:1508-12. [PMID: 25899242 DOI: 10.1161/strokeaha.115.008804] [Citation(s) in RCA: 184] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 02/25/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We derived and validated the Cincinnati Prehospital Stroke Severity Scale (CPSSS) to identify patients with severe strokes and large vessel occlusion (LVO). METHODS CPSSS was developed with regression tree analysis, objectivity, anticipated ease in administration by emergency medical services personnel and the presence of cortical signs. We derived and validated the tool using the 2 National Institute of Neurological Disorders and Stroke (NINDS) tissue-type plasminogen activator Stroke Study trials and Interventional Management of Stroke III (IMS III) Trial cohorts, respectively, to predict severe stroke (National Institutes of Health Stroke Scale [NIHSS]≥15) and LVO. Standard test characteristics were determined and receiver operator curves were generated and summarized by the area under the curve. RESULTS CPSSS score ranges from 0 to 4; composed and scored by individual NIHSS items: 2 points for presence of conjugate gaze (NIHSS≥1); 1 point for presence of arm weakness (NIHSS≥2); and 1 point for presence abnormal level of consciousness commands and questions (NIHSS level of consciousness≥1 each). In the derivation set, CPSSS had an area under the curve of 0.89; score≥2 was 89% sensitive and 73% specific in identifying NIHSS≥15. Validation results were similar with an area under the curve of 0.83; score≥2 was 92% sensitive, 51% specific, a positive likelihood ratio of 3.3, and a negative likelihood ratio of 0.15 in predicting severe stroke. For 222 of 303 IMS III subjects with LVO, CPSSS had an area under the curve of 0.67; a score≥2 was 83% sensitive, 40% specific, positive likelihood ratio of 1.4, and negative likelihood ratio of 0.4 in predicting LVO. CONCLUSIONS CPSSS can identify stroke patients with NIHSS≥15 and LVO. Prospective prehospital validation is warranted.
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Affiliation(s)
- Brian S Katz
- From the Department of Neurology (B.S.K., J.P.B.) and Department of Emergency Medicine (J.T.M., O.A.), University of Cincinnati, College of Medicine, OH; and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.).
| | - Jason T McMullan
- From the Department of Neurology (B.S.K., J.P.B.) and Department of Emergency Medicine (J.T.M., O.A.), University of Cincinnati, College of Medicine, OH; and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.)
| | - Heidi Sucharew
- From the Department of Neurology (B.S.K., J.P.B.) and Department of Emergency Medicine (J.T.M., O.A.), University of Cincinnati, College of Medicine, OH; and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.)
| | - Opeolu Adeoye
- From the Department of Neurology (B.S.K., J.P.B.) and Department of Emergency Medicine (J.T.M., O.A.), University of Cincinnati, College of Medicine, OH; and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.)
| | - Joseph P Broderick
- From the Department of Neurology (B.S.K., J.P.B.) and Department of Emergency Medicine (J.T.M., O.A.), University of Cincinnati, College of Medicine, OH; and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (H.S.)
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15
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Barlinn K, Tsivgoulis G, Barreto AD, Alleman J, Molina CA, Mikulik R, Saqqur M, Demchuk AM, Schellinger PD, Howard G, Alexandrov AV. Outcomes following sonothrombolysis in severe acute ischemic stroke: subgroup analysis of the CLOTBUST trial. Int J Stroke 2014; 9:1006-10. [PMID: 25079049 DOI: 10.1111/ijs.12340] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 05/20/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Sonothrombolysis is safe and may increase the likelihood of early recanalization in acute ischemic stroke patients. AIMS In preparation of a phase III clinical trial, we contrast the likelihood of achieving a sustained recanalization and functional independence in a post hoc subgroup analysis of patients randomized to transcranial Doppler monitoring plus intravenous tissue plasminogen activator (sonothrombolysis) compared with intravenous tissue plasminogen activator alone in the CLOTBUST trial. METHODS We analyzed the data from all randomized acute ischemic stroke patients with pretreatment National Institutes of Health Stroke Scale scores ≥ 10 points and proximal intracranial occlusions in the CLOTBUST trial. We compared sustained complete recanalization rate (Thrombolysis in Brain Ischemia flow grades 4-5) and functional independence (modified Rankin Scale 0-1) at 90 days. Safety was evaluated by the rate of symptomatic intracranial hemorrhage within 72 h of stroke onset. RESULTS Of 126 patients, a total of 85 acute ischemic stroke patients met our inclusion criteria: mean age 71 ± 11years, 56% men, median National Institutes of Health Stroke Scale 17 (interquartile range 14-20). Of these patients, 41 (48%) and 44 (52%) were randomized to intravenous tissue plasminogen activator alone and sonothrombolysis, respectively. More patients achieved sustained complete recanalization in the sonothrombolysis than in the intravenous tissue plasminogen activator alone group (38·6% vs. 17·1%; P = 0·032). Functional independence at 90 days was more frequently achieved in the sonothrombolysis than in the intravenous tissue plasminogen activator alone group (37·2% vs. 15·8%; P = 0·045). Symptomatic intracranial hemorrhage rate was similar in both groups (4·9% vs. 4·6%; P = 1·00). CONCLUSIONS Our results point to a signal of efficacy and provide information to guide the subsequent phase III randomized trial of sonothrombolysis in patients with severe ischemic strokes.
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Affiliation(s)
- Kristian Barlinn
- Dresden University Stroke Center, Department of Neurology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
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