Journal: J Stroke

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<div><h4>Practical Nomogram Predicting Apixaban or Rivaroxaban Concentrations from Low-Molecular-Weight Heparin Anti-Xa Values: Special Interest in Acute Ischemic Stroke Patients.</h4><i>Brakta C, Stépanian A, Reiner P, Delrue M, ... Curis E, Siguret V</i><br /><b>Background:</b><br/>and purpose</b><br />In patients with acute ischemic stroke (AIS) using a direct oral factor-Xa anticoagulant (DOAC) during the last 48 hours, a fixed plasma heparin-calibrated anti-Xa activity (0.5 IU/mL) was proposed as a threshold below which patients could be eligible for thrombolysis and/or thrombectomy. Besides, specific DOAC-calibrated anti-Xa thresholds up to 50 ng/mL have been proposed. However, specific DOAC assays are not widely available contrarily to low-molecularweight heparin (LMWH) anti-Xa activity. We developed and validated a nomogram for predicting apixaban and rivaroxaban concentrations based on LMWH anti-Xa assay.<br /><b>Methods</b><br />Our prospective study included apixaban (n=325) and rivaroxaban (n=276) patients. On the same sample, we systematically measured specific DOAC concentration and LMWH anti-Xa activity, using STA®-Liquid-Anti-Xa (Stago) and specific DOAC- or LMWH-calibrators, respectively. The nomogram was built using quantifiable values for both assays on the derivation cohorts with a log-linear regression model. Model performances including sensitivity, specificity, and true positive rate for different thresholds were checked on the validation cohorts.<br /><b>Results</b><br />The models built from the derivation cohorts predicted that values <30 ng/mL and <50 ng/ mL DOAC thresholds corresponded to LMWH-anti-Xa values <0.10 IU/mL and <0.64 IU/mL for apixaban; <0.10 IU/mL and <0.71 IU/mL for rivaroxaban. The model accurately predicted apixaban/ rivaroxaban concentrations in the validation cohort.<br /><b>Conclusions</b><br />This easy-to-use nomogram, developed with our reagent, allowed accurately predicting DOAC concentrations based on LMWH-anti-Xa results in emergency situations such as AIS when drug-specific assessments are not rapidly available. Using DOAC <50 ng/mL equivalent threshold, instead of the fixed LMWH <0.5 IU/mL one, would allow proposing thrombolysis to more patients.<br /><br /><br /><br /><small>J Stroke: 03 Jan 2023; epub ahead of print</small></div>
Brakta C, Stépanian A, Reiner P, Delrue M, ... Curis E, Siguret V
J Stroke: 03 Jan 2023; epub ahead of print | PMID: 36592965
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<div><h4>Mechanical Thrombectomy for Acute Ischemic Stroke in Metastatic Cancer Patients: A Nationwide Cross-Sectional Analysis.</h4><i>Aboul-Nour H, Maraey A, Jumah A, Khalil M, ... Miller DJ, Mayer SA</i><br /><b>Background:</b><br/>and purpose</b><br />Mechanical thrombectomy (MT) is the standard treatment for large vessel occlusion (LVO) acute ischemic stroke. Patients with active malignancy have an increased risk of stroke but were excluded from MT trials.<br /><b>Methods</b><br />We searched the National Readmission Database for LVO patients treated with MT between 2016-2018 and compared the characteristics and outcomes of cancer-free patients to those with metastatic cancer (MC). Primary outcomes were all-cause in-hospital mortality and favorable outcome, defined as a routine discharge to home (regardless of whether home services were provided or not). Multivariate regression was used to adjust for confounders.<br /><b>Results</b><br />Of 40,537 LVO patients treated with MT, 933 (2.3%) had MC diagnosis. Compared to cancer-free patients, MC patients were similar in age and stroke severity but had greater overall disease severity. Hospital complications that occurred more frequently in MC included pneumonia, sepsis, acute coronary syndrome, deep vein thrombosis, and pulmonary embolism (P<0.001). Patients with MC had similar rates of intracerebral hemorrhage (20% vs. 21%) but were less likely to receive tissue plasminogen activator (13% vs. 23%, P<0.001). In unadjusted analysis, MC patients as compared to cancer-free patients had a higher in-hospital mortality rate and were less likely to be discharged to home (36% vs. 42%, P=0.014). On multivariate regression adjusting for confounders, mortality was the only outcome that was significantly higher in the MC group than in the cancerfree group (P<0.001). <br /><b>Conclusion:</b><br/>LVO patients with MC have higher mortality and more infectious and thrombotic complications than cancer-free patients. MT nonetheless can result in survival with good outcome in slightly over one-third of patients.<br /><br /><br /><br /><small>J Stroke: 03 Jan 2023; epub ahead of print</small></div>
Aboul-Nour H, Maraey A, Jumah A, Khalil M, ... Miller DJ, Mayer SA
J Stroke: 03 Jan 2023; epub ahead of print | PMID: 36592967
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<div><h4>Diabetes and Stroke: What Are the Connections?</h4><i>Mosenzon O, Cheng AY, Rabinstein AA, Sacco S</i><br /><AbstractText>Stroke is a major cause of death and long-term disability worldwide. Diabetes is associated with an increased risk of cardiovascular complications, including stroke. People with diabetes have a 1.5-2 times higher risk of stroke compared with people without diabetes, with risk increasing with diabetes duration. These risks may also differ according to sex, with a greater risk observed among women versus men. Several mechanisms associated with diabetes lead to stroke, including large artery atherosclerosis, cerebral small vessel disease, and cardiac embolism. Hyperglycemia confers increased risk for worse outcomes in people presenting with acute ischemic stroke, compared with people with normal glycemia. Moreover, people with diabetes may have poorer post-stroke outcomes and higher risk of stroke recurrence than those without diabetes. Appropriate management of diabetes and other vascular risk factors may improve stroke outcomes and reduce the risk for recurrent stroke. Secondary stroke prevention guidelines recommend screening for diabetes following a stroke. The diabetes medications pioglitazone and glucagon-like peptide-1 receptor agonists have demonstrated protection against stroke in randomized controlled trials; this protective effect is believed to be independent of glycemic control. Neurologists are often involved in the management of modifiable risk factors for stroke (including hypertension, hyperlipidemia, and atrial fibrillation), but less often in the direct management of diabetes. This review provides an overview of the relationships between diabetes and stroke, including epidemiology, pathophysiology, post-stroke outcomes, and treatments for people with stroke and diabetes. This should aid neurologists in diabetes-related decision-making when treating people with acute or recurrent stroke.</AbstractText><br /><br /><br /><br /><small>J Stroke: 03 Jan 2023; epub ahead of print</small></div>
Mosenzon O, Cheng AY, Rabinstein AA, Sacco S
J Stroke: 03 Jan 2023; epub ahead of print | PMID: 36592968
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<div><h4>Cortical Thinning in High-Grade Asymptomatic Carotid Stenosis.</h4><i>Marshall RS, Liebeskind DS, Iii JH, Edwards LJ, ... Brickman AM, Lazar RM</i><br /><b>Background:</b><br/>and purpose</b><br />High-grade carotid artery stenosis may alter hemodynamics in the ipsilateral hemisphere, but consequences of this effect are poorly understood. Cortical thinning is associated with cognitive impairment in dementia, head trauma, demyelination, and stroke. We hypothesized that hemodynamic impairment, as represented by a relative time-to-peak (TTP) delay on MRI in the hemisphere ipsilateral to the stenosis, would be associated with relative cortical thinning in that hemisphere.<br /><b>Methods</b><br />We used baseline MRI data from the NINDS-funded Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis-Hemodynamics (CREST-H) study. Dynamic contrast susceptibility MR perfusion-weighted images were post-processed with quantitative perfusion maps using deconvolution of tissue and arterial signals. The protocol derived a hemispheric TTP delay, calculated by subtraction of voxel values in the hemisphere ipsilateral minus those contralateral to the stenosis.<br /><b>Results</b><br />Among 110 consecutive patients enrolled in CREST-H to date, 45 (41%) had TTP delay of at least 0.5 seconds and 9 (8.3%) subjects had TTP delay of at least 2.0 seconds, the maximum delay measured. For every 0.25-second increase in TTP delay above 0.5 seconds, there was a 0.006-mm (6 micron) increase in cortical thickness asymmetry. Across the range of hemodynamic impairment, TTP delay independently predicted relative cortical thinning on the side of stenosis, adjusting for age, sex, hypertension, hemisphere, smoking history, low-density lipoprotein cholesterol, and preexisting infarction (P=0.032).<br /><b>Conclusions</b><br />Our findings suggest that hemodynamic impairment from high-grade asymptomatic carotid stenosis may structurally alter the cortex supplied by the stenotic carotid artery.<br /><br /><br /><br /><small>J Stroke: 03 Jan 2023; epub ahead of print</small></div>
Marshall RS, Liebeskind DS, Iii JH, Edwards LJ, ... Brickman AM, Lazar RM
J Stroke: 03 Jan 2023; epub ahead of print | PMID: 36592969
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<div><h4>Trends in Venous Thromboembolism Readmission Rates after Ischemic Stroke and Intracerebral Hemorrhage.</h4><i>Shu L, Havenon A, Liberman AL, Henninger N, ... Furie K, Yaghi S</i><br /><b>Background:</b><br/>and purpose</b><br />Venous thromboembolism (VTE) is a life-threatening complication of stroke. We evaluated nationwide rates and risk factors for hospital readmissions with VTE after an intracerebral hemorrhage (ICH) or acute ischemic stroke (AIS) hospitalization.<br /><b>Methods</b><br />Using the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmission Database, we included patients with a principal discharge diagnosis of ICH or AIS from 2016 to 2019. Patients who had VTE diagnosis or history of VTE during the index admission were excluded. We performed Cox regression models to determine factors associated with VTE readmission, compared rates between AIS and ICH and developed post-stroke VTE risk score. We estimated VTE readmission rates per day over a 90-day time window post-discharge using linear splines.<br /><b>Results</b><br />Of the total 1,459,865 patients with stroke, readmission with VTE as the principal diagnosis within 90 days occurred in 0.26% (3,407/1,330,584) AIS and 0.65% (843/129,281) ICH patients. The rate of VTE readmission decreased within first 4-6 weeks (P<0.001). In AIS, cancer, obesity, higher National Institutes of Health Stroke Scale (NIHSS) score, longer hospital stay, home or rehabilitation disposition, and absence of atrial fibrillation were associated with VTE readmission. In ICH, longer hospital stay and rehabilitation disposition were associated with VTE readmission. The VTE rate was higher in ICH compared to AIS (adjusted hazard ratio 2.86, 95% confidence interval 1.93-4.25, P<0.001).<br /><b>Conclusions</b><br />After stroke, VTE readmission risk is highest within the first 4-6 weeks and nearly three-fold higher after ICH vs. AIS. VTE risk is linked to decreased mobility and hypercoagulability. Studies are needed to test short-term VTE prophylaxis beyond hospitalization in high-risk patients.<br /><br /><br /><br /><small>J Stroke: 03 Jan 2023; epub ahead of print</small></div>
Shu L, Havenon A, Liberman AL, Henninger N, ... Furie K, Yaghi S
J Stroke: 03 Jan 2023; epub ahead of print | PMID: 36592970
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<div><h4>The Heart Is at Risk: Understanding Stroke-Heart-Brain Interactions with Focus on Neurogenic Stress Cardiomyopathy-A Review.</h4><i>Ziaka M, Exadaktylos A</i><br /><AbstractText>In recent years, it has been convincingly demonstrated that acute brain injury may cause severe cardiac complications-such as neurogenic stress cardiomyopathy (NSC), a specific form of takotsubo cardiomyopathy. The pathophysiology of these brain-heart interactions is complex and involves sympathetic hyperactivity, activation of the hypothalamic-pituitary-adrenal axis, as well as immune and inflammatory pathways. There have been great strides in our understanding of the axis from the brain to the heart in patients with isolated acute brain injury and more specifically in patients with stroke. On the other hand, in patients with NSC, research has mainly focused on hemodynamic dysfunction due to arrhythmias, regional wall motion abnormality, or left ventricular hypokinesia that leads to impaired cerebral perfusion pressure. Comparatively little is known about the underlying secondary and delayed cerebral complications. The aim of the present review is to describe the stroke-heart-brain axis and highlight the main pathophysiological mechanisms leading to secondary and delayed cerebral injury in patients with concurrent hemorrhagic or ischemic stroke and NSC as well as to identify further areas of research that could potentially improve outcomes in this specific patient population.</AbstractText><br /><br /><br /><br /><small>J Stroke: 03 Jan 2023; epub ahead of print</small></div>
Ziaka M, Exadaktylos A
J Stroke: 03 Jan 2023; epub ahead of print | PMID: 36592971
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<div><h4>Impact of Left Atrial or Left Atrial Appendage Thrombus on Stroke Outcome: A Matched Control Analysis.</h4><i>Heo J, Lee H, Lee IH, Nam HS, Kim YD</i><br /><b>Background:</b><br/>and purpose</b><br />Left atrial or left atrial appendage (LA/LAA) thrombi are frequently observed during cardioembolic evaluation in patients with ischemic stroke. This study aimed to investigate stroke outcomes in patients with LA/LAA thrombus.<br /><b>Methods</b><br />This retrospective study included patients admitted to a single tertiary center in Korea between January 2012 and December 2020. Patients with nonvalvular atrial fibrillation who underwent transesophageal echocardiography or multi-detector coronary computed tomography were included in the study. Poor outcome was defined as modified Rankin Scale score >3 at 90 days. The inverse probability of treatment weighting analysis was performed.<br /><b>Results</b><br />Of the 631 patients included in this study, 68 (10.7%) had LA/LAA thrombi. Patients were likely to have a poor outcome when an LA/LAA thrombus was detected (42.6% vs. 17.4%, P<0.001). Inverse probability of treatment weighting analysis yielded a higher probability of poor outcomes in patients with LA/LAA thrombus than in those without LA/LAA thrombus (P<0.001). Patients with LA/LAA thrombus were more likely to have relevant arterial occlusion on angiography (36.3% vs. 22.4%, P=0.047) and a longer hospital stay (8 vs. 7 days, P<0.001) than those without LA/LAA thrombus. However, there was no difference in early neurological deterioration during hospitalization or major adverse cardiovascular events within 3 months between the two groups.<br /><b>Conclusions</b><br />Patients with ischemic stroke who had an LA/LAA thrombus were at risk of a worse functional outcome after 3 months, which was associated with relevant arterial occlusion and prolonged hospital stay.<br /><br /><br /><br /><small>J Stroke: 03 Jan 2023; epub ahead of print</small></div>
Heo J, Lee H, Lee IH, Nam HS, Kim YD
J Stroke: 03 Jan 2023; epub ahead of print | PMID: 36592972
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<div><h4>Cerebral Edema in Patients with severe Hemispheric Syndrome: Incidence, Risk Factors, and Outcomes. Data from SITS-ISTR.</h4><i>Escudero-Martínez I, Thorén M, Ringleb P, Nunes AP, ... Tsao N, Ahmed N</i><br /><b>Background:</b><br/>and purpose</b><br />Cerebral edema (CED) in ischemic stroke can worsen prognosis and about 70% of patients who develop severe CED die if treated conservatively. We aimed to describe incidence, risk factors and outcomes of CED in patients with extensive ischemia.<br /><b>Methods</b><br />Oservational study based on Safe Implementation of Treatments in Stroke-International Stroke Treatment Registry (2003-2019). Severe hemispheric syndrome (SHS) at baseline and persistent SHS (pSHS) at 24 hours were defined as National Institutes of Health Stroke Score (NIHSS) >15. Outcomes were moderate/severe CED detected by neuroimaging, functional independence (modified Rankin Scale 0-2) and death at 90 days.<br /><b>Results</b><br />Patients (n=8,560) presented with SHS and developed pSHS at 24 hours; 82.2% received intravenous thrombolysis (IVT), 10.5% IVT+thrombectomy, and 7.3% thrombectomy alone. Median age was 77 and NIHSS 21. Of 7,949 patients with CED data, 3,780 (47.6%) had any CED and 2,297 (28.9%) moderate/severe CED. In the multivariable analysis, age <50 years (relative risk [RR], 1.56), signs of acute infarct (RR, 1.29), hyperdense artery sign (RR, 1.39), blood glucose >128.5 mg/dL (RR, 1.21), and decreased level of consciousness (RR, 1.14) were associated with moderate/severe CED (for all P<0.05). Patients with moderate/severe CED had lower odds to achieve functional Independence (adjusted odds ratio [aOR], 0.35; 95% confidence interval [CI], 0.23 to 0.55) and higher odds of death at 90 days (aOR, 2.54; 95% CI, 2.14 to 3.02).<br /><b>Conclusions</b><br />In patients with extensive ischemia, the most important predictors for moderate/ severe CED were age <50, high blood glucose, signs of acute infarct, hyperdense artery on baseline scans, and decreased level of consciousness. CED was associated with worse functional outcome and a higher risk of death at 3 months.<br /><br /><br /><br /><small>J Stroke: 06 Dec 2022; epub ahead of print</small></div>
Escudero-Martínez I, Thorén M, Ringleb P, Nunes AP, ... Tsao N, Ahmed N
J Stroke: 06 Dec 2022; epub ahead of print | PMID: 36470246
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