RESUMEN
BACKGROUND AND PURPOSE: Blood pressure (BP) variability has been associated with worse neurological outcomes in acute ischaemic stroke (AIS) patients receiving treatment with intravenous thrombolysis (IVT). However, no study to date has investigated whether pulse pressure (PP) variability may be a superior indicator of the total cardiovascular risk, as measured by clinical outcomes. METHODS: Pulse pressure variability was calculated from 24-h PP measurements following tissue plasminogen activator bolus in AIS patients enrolled in the Combined Lysis of Thrombus using Ultrasound and Systemic Tissue Plasminogen Activator for Emergent Revascularization (CLOTBUST-ER) trial. The outcomes of interest were the pre-specified efficacy and safety end-points of CLOTBUST-ER. All associations were adjusted for potential confounders in multivariable regression models. RESULTS: Data from 674 participants was analyzed. PP variability was identified as the BP parameter with the most parsimonious fit in multivariable models of all outcomes, and was independently associated (P < 0.001) with lower likelihood of both 24-h neurological improvement and 90-day independent functional outcome. PP variability was also independently related to increased odds of any intracranial bleeding (P = 0.011) and 90-day mortality (P < 0.001). Every 5-mmHg increase in the 24-h PP variability was independently associated with a 36% decrease in the likelihood of 90-day independent functional outcome (adjusted odds ratio 0.64, 95% confidence interval 0.52-0.80) and a 60% increase in the odds of 90-day mortality (adjusted odds ratio 1.60, 95% confidence interval 1.23-2.07). PP variability was not associated with symptomatic intracranial bleeding at either 24 or 36 h after IVT administration. CONCLUSIONS: Increased PP variability appears to be independently associated with adverse short-term and long-term functional outcomes of AIS patients treated with IVT.
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Isquemia Encefálica , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Administración Intravenosa , Presión Sanguínea , Isquemia Encefálica/complicaciones , Isquemia Encefálica/tratamiento farmacológico , Fibrinolíticos/uso terapéutico , Humanos , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Activador de Tejido Plasminógeno/uso terapéutico , Resultado del TratamientoRESUMEN
PURPOSE: New software solutions emerged to support radiologists in image interpretation in acute ischemic stroke. This study aimed to validate the performance of computer-aided assessment of the Alberta Stroke Program Early CT score (ASPECTS) for detecting signs of early infarction. METHODS: ASPECT scores were assessed in 119 CT scans of patients with acute middle cerebral artery ischemia. Patient collective was differentiated according to (I) normal brain, (II) leukoencephalopathic changes, (III) infarcts, and (IV) atypical parenchymal defects (multiple sclerosis, etc.). ASPECTS assessments were automatically provided by the software package e-ASPECTS (Brainomix®, UK) (A). Subsequently, three neuroradiologists (B), (C), and (D) examined independently 2380 brain regions. Interrater comparison was performed with the definite infarct core as reference standard after best medical care (thrombolysis and/or thrombectomy). RESULTS: Interrater comparison revealed higher correlation coefficient of (B) 0.71, (C) 0.76, and of (D) 0.80 with definite infarct core compared to (A) 0.59 for ASPECTS assessment in the acute ischemic stroke setting. While (B), (C), and (D) showed a significant correlation for individual patient groups (I), (II), (III), and (IV), except for (D) (II), (A) was not significant in patient groups with pre-existing changes (II), (III), and (IV). The following sensitivities, specificities, PPV, NPV, and accuracies given in percent were achieved: (A) 83, 57, 55, 82, and 67; (B) 74, 76, 69, 83, and 77; (C) 80.8, 85.2, 76, 84, and 80; (D) 63, 90.7, 82, 79, and 80, respectively. CONCLUSION: For ASPECTS assessment, the examined software may provide valid data in case of normal brain. It may enhance the work of neuroradiologists in clinical decision making. A final human check for plausibility is needed, particularly in patient groups with pre-existing cerebral changes.
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Isquemia Encefálica/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Aprendizaje Automático , Interpretación de Imagen Radiográfica Asistida por Computador/métodos , Accidente Cerebrovascular/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Adulto , Anciano , Anciano de 80 o más Años , Alberta , Femenino , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Sensibilidad y Especificidad , Programas InformáticosRESUMEN
BACKGROUND AND PURPOSE: Intracranial hemorrhage (ICH) is the most feared complication in patients treated with oral anticoagulants due to non-valvular atrial fibrillation. Non-vitamin K oral anticoagulants (NOACs) reduce the risk of ICH compared with vitamin K antagonists (VKAs). We performed a systematic review and meta-analysis to evaluate the risk of fatal NOAC-related ICH compared with VKA-related ICH. METHODS: We calculated the corresponding risk ratios (RRs) in each included study to express the relative risk of fatal ICH amongst all patients receiving oral anticoagulation with either NOACs or VKAs. We additionally evaluated the mortality rates in NOAC-related ICH in patients treated with and without NOAC-specific reversal agents (idarucizumab and factor Xa inhibitors antidote). Case fatality was evaluated at 30-90 days following symptom onset. RESULTS: Our literature search identified six eligible studies (four randomized controlled trials and two open-label trials of NOAC-specific reversal agents). In pairwise analyses, NOACs were found to have a lower risk of fatal ICH compared with VKAs [RR, 0.46; 95% confidence interval (CI), 0.36-0.58] with no heterogeneity (I2 = 0%) across included randomized controlled trials. However, the case fatality rate was similar in NOAC-related and VKA-related (RR, 1.00; 95% CI, 0.84-1.19) ICH with no evidence of heterogeneity (I2 = 0%). In the indirect analysis, the case fatality rate of NOAC-related ICH in patients treated with specific reversal agents was lower compared with the remainder of the patients [17% (95% CI, 11-24%) vs. 41% (95% CI, 34-49%); P < 0.001]. CONCLUSIONS: Non-vitamin K oral anticoagulants halve the risk of fatal ICH in patients with non-valvular atrial fibrillation compared with VKAs, whereas indirect comparisons indicate that NOAC-specific reversal agents may be associated with a lower case fatality rate in NOAC-related ICH.
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Anticoagulantes/efectos adversos , Hemorragias Intracraneales/inducido químicamente , Administración Oral , Anticoagulantes/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Humanos , RiesgoRESUMEN
The standard of care for patients with acute stroke of the anterior circulation and large vessel occlusion is the combined treatment with intravenous rt-PA (recombinant tissue-type plasminogen activator) and endovascular thrombectomy. The therapy is highly effective while reducing functional deficits and long-term disability. International guidelines recommend thrombectomy during the first 6 h after symptom onset, but new evidence supports its use in selected patients within a time window of up to 24 h. Eligible patients show a clinical core mismatch, i. e. severe neurologic deficits contrasting to a small core of cerebral infarction. Future research questions regard the treatment of vessel occlusion at the M2 segments as well as the best anesthetic management during the intervention. The infrastructure of stroke care especially in rural areas is based on the drip-and-ship paradigm that implies emergency treatment with the start of intravenous thrombolysis at the nearest hospital followed by transport to an interventional center in case of large vessel occlusion.
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Infarto Cerebral/terapia , Procedimientos Endovasculares/métodos , Accidente Cerebrovascular/terapia , Trombectomía/métodos , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/uso terapéutico , Infarto Cerebral/diagnóstico , Sedación Consciente , Alemania , Humanos , Examen Neurológico , Transferencia de Pacientes , Pronóstico , Servicios de Salud Rural , Accidente Cerebrovascular/diagnóstico , Factores de TiempoRESUMEN
OBJECTIVE: How can the overwhelmingly positive results of the five randomized thrombectomy trials published in 2015 be transferred to the clinical routine? MATERIAL AND METHODS: Analysis of trial-specific characteristics with regard to implementation of mechanical thrombectomy into clinical routine. RESULTS: Stroke patients with symptomatic proximal artery occlusion are principally eligible for mechanical thrombectomy; however, the stroke patients included in the thrombectomy trials are not representative of all stroke patients. They were carefully selected according to clinical and imaging criteria as well as to the time window from symptom onset. Furthermore, they were treated in highly selected specialized stroke centers. Analysis of the five trials and the Catalan population-based SONIIA registry revealed that the observed number needed to treat (NNT) of 5 to reach a modified Rankin scale (mRS) score of 0-2 only applies to approximately 1 % of all stroke patients. The NNT for the remaining patients who are principally eligible for thrombectomy requires further study. Currently, centralization seems to be useful to facilitate mechanical thrombectomy in routine care leading to several problems that have to be dealt with in particular regions. Secondary transport to thrombectomy centers plays a major role in this context and has to be provided with highest priority. CONCLUSION: Only careful analysis of study results and the background circumstances will enable adequate organization and successful practical implementation of this highly effective therapy in the clinical routine. Regional conditions have to be considered and will be crucial in this context.
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Ensayos Clínicos como Asunto , Trombolisis Mecánica/estadística & datos numéricos , Evaluación del Resultado de la Atención al Paciente , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/cirugía , Medicina Basada en la Evidencia , Humanos , Prevalencia , Tamaño de la Muestra , Accidente Cerebrovascular/diagnóstico , Resultado del TratamientoRESUMEN
PURPOSE: It has been reported that the extent of intravascular thrombi and the quality of collateral filling in computed tomography (CT) angiography are predictive for the clinical outcome in patients with acute stroke. We hypothesized that multi-phase four-dimensional CTA (4D-CTA) allows better assessment of clot burden and collateral flow compared with arterial single-phase CTA (CTA). METHODS: In 49 patients (33 female; age: 77 ± 12 years) with acute anterior circulation stroke, CTA and 4D-CTA reconstructed from dynamic perfusion CT data were analyzed for absolute thrombus length (TL), clot burden score (CBS), and collateral score (CS). The length of the filling defect was also defined on thin-slice nonenhanced CT as corresponding hyperdense middle cerebral artery sign (HMCAS) when present. RESULTS: There was good correlation (r = 0.62, p < 0.01) between the length of HMCAS (1.29 ± 0.62 cm) and TL in 4D-CTA (1.22 ± 0.51 cm). 4D-CTA and CTA significantly varied (p < 0.01) in TL (1.42 ± 0.73 cm (CTA) versus 1.11 ± 0.62 cm (4D-CTA)), CBS (median: 5, interquartile range: 4-7 (CTA) versus median: 6, interquartile range: 5-8 (4D-CTA); p < 0.001), and CS (median: 2, interquartile range: 1-2 (CTA) versus median: 3, interquartile range: 2-3 (4D-CTA); p < 0.001). Accordingly, CTA significantly overrated clot burden and underestimated collateral flow. CONCLUSIONS: 4D-CTA more closely defines clot burden and collateral supply in anterior circulation stroke than CTA, implicating an additional diagnostic benefit.
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Infarto Encefálico/diagnóstico por imagen , Angiografía Cerebral/métodos , Angiografía por Tomografía Computarizada/métodos , Tomografía Computarizada Cuatridimensional/métodos , Trombosis Intracraneal/diagnóstico por imagen , Intensificación de Imagen Radiográfica/métodos , Anciano , Algoritmos , Infarto Encefálico/complicaciones , Diagnóstico Diferencial , Femenino , Humanos , Trombosis Intracraneal/etiología , Masculino , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadAsunto(s)
Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/cirugía , Revascularización Cerebral/instrumentación , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/cirugía , Stents , Enfermedad Aguda , Anciano , Prótesis Vascular , Revascularización Cerebral/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Cirugía Asistida por Computador/métodos , Resultado del TratamientoAsunto(s)
Anticoagulantes/uso terapéutico , Apéndice Atrial/cirugía , Fibrilación Atrial/complicaciones , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & control , Oclusión Terapéutica/métodos , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/cirugía , Medicina Basada en la Evidencia , Humanos , Medición de Riesgo , Oclusión Terapéutica/instrumentación , Resultado del TratamientoRESUMEN
Immunologically mediated heparin-induced thrombocytopenia (HIT) is a thrombotic disease caused by antibodies occurring after heparin exposure. Thrombocytopenia occurs within a few days after heparin exposure, about half of HIT-patients develop venous or arterial thrombotic complications. Neurological complications of HIT are mainly ischaemic stroke and sinus vein thrombosis. To ensure the primary clinical diagnosis functional and immunological assays for antibody detection are available. The probability for the occurrence of HIT depends on the nature of heparin employed (LMWH vs. UFH) and individual patient characteristics such as gender and primary disease (medical vs. surgical patients). In the case of suspected HIT heparin administration should be discontinued immediately and replaced by an alternative anticoagulation to prevent the expansion or development of further thrombotic complications. Herein we report a case of a patient suffering from HIT-associated embolic cerebral ischaemic stroke.
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Anticoagulantes/efectos adversos , Trastornos Cerebrovasculares/etiología , Heparina/efectos adversos , Trombocitopenia/complicaciones , Trombocitopenia/inmunología , Anciano , Anticuerpos/análisis , Anticuerpos/inmunología , Anticoagulantes/química , Isquemia Encefálica/etiología , Trastornos Cerebrovasculares/epidemiología , Ecocardiografía Transesofágica , Heparina/química , Heparina de Bajo-Peso-Molecular/efectos adversos , Heparina de Bajo-Peso-Molecular/uso terapéutico , Humanos , Trombosis Intracraneal/etiología , Trombosis Intracraneal/prevención & control , Masculino , Trombosis de los Senos Intracraneales/etiología , Accidente Cerebrovascular/etiología , Trombocitopenia/inducido químicamenteRESUMEN
BACKGROUND AND PURPOSE: The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial showed a trend for reduced all-cause mortality and positive secondary safety end point outcomes. We present further analyses of the mortality and severe disability data from the Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial. MATERIALS AND METHODS: The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial was a multicenter, randomized, controlled trial that evaluated the safety and effectiveness of the NeuroFlo catheter in patients with stroke. The current analysis was performed on the as-treated population. All-cause and stroke-related mortality rates at 90 days were compared between groups, and logistic regression models were fit to obtain ORs and 95% CIs for the treated versus not-treated groups. We categorized death-associated serious adverse events as neurologic versus non-neurologic events and performed multiple logistic regression analyses. We analyzed severe disability and mortality by outcomes of the mRS. Patient allocation was gathered by use of a poststudy survey. RESULTS: All-cause mortality trended in favor of treated patients (11.5% versus 16.1%; P = .079) and stroke-related mortality was significantly reduced in treated patients (7.5% versus 14.2%; P = .009). Logistic regression analysis for freedom from stroke-related mortality favored treatment (OR, 2.41; 95% CI, 1.22, 4.77; P = .012). Treated patients had numerically fewer neurologic causes of stroke-related deaths (52.9% versus 73.0%; P = .214). Among the 90-day survivors, nominally fewer treated patients were severely disabled (mRS 5) (5.6% versus 7.5%; OR, 1.72; 95% CI, 0.72, 4.14; P = .223). Differences in allocation of care did not account for the reduced mortality rates. CONCLUSIONS: There were consistent reductions in all-cause and stroke-related mortality in the NeuroFlo-treated patients. This reduction in mortality did not result in an increase in severe disability.
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Isquemia Encefálica/mortalidad , Isquemia Encefálica/terapia , Evaluación de la Discapacidad , Enfermedades del Sistema Nervioso/mortalidad , Enfermedades del Sistema Nervioso/prevención & control , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/terapia , Oclusión Terapéutica/mortalidad , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Femenino , Humanos , Incidencia , Internacionalidad , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/diagnóstico , Medición de Riesgo , Accidente Cerebrovascular/diagnóstico , Tasa de Supervivencia , Oclusión Terapéutica/métodos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Platelet counts (PCs) <100,000/µl are considered as a contraindication for intravenous thrombolysis (IVT). While US guidelines recommend IVT initiation before the availability of clotting tests, the guidelines of the European Stroke Organization give no such practical advice. We aimed to assess the incidence of thrombocytopenia in IVT patients, outcome after thrombolysis in affected patients and the time gained by initiating treatment prior to availability of PC results. METHODS: All patients with thrombocytopenia were identified in our prospectively acquired thrombolysis database. Baseline demographic data, intracerebral hemorrhage rates as well as functional outcome were assessed. The median time between initiation of thrombolysis and availability of PCs was calculated. RESULTS: Of 625 IVT patients, 3 (0.5%) had thrombocytopenia at stroke onset. None of them developed intracerebral hemorrhage (ICH) or died during the follow-up. Waiting for PCs would have delayed treatment in 72.4% of the patients, with a median hypothetical delay of 22 min (interquartile range: 11-41 min). CONCLUSIONS: To date, there are no sufficient data to evaluate the ICH risk in thrombocytopenic patients. However, thrombocytopenia is rare in IVT patients. Thus, generally waiting for PC results prior to initiation of IVT is not warranted. Avoiding this significant delay yields shorter door-to-needle times and potentially more effective treatment.
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Recuento de Plaquetas , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/efectos adversos , Anciano , Femenino , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Factores de TiempoRESUMEN
BACKGROUND: This article gives an up-to-date overview of neurosonographic emergency and intensive care diagnostics. METHODS: Selective literature research from 1984 with critical appraisal and including national and international guidelines. RESULTS: Fast and valid diagnostics in acute stroke is the main field of application of neurosonography. Specific monitoring methods bear great advantages for intensive care patients, especially "as-often-as-wanted" repetitive imaging under real-time conditions. A number of new developments make neurosonography an interesting area of research. CONCLUSIONS: Neurosonography has played a key role in neurological emergency and intensive care medicine for many years. It remains important to continuously support dissemination of the method.
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Muerte Encefálica/diagnóstico por imagen , Estenosis Carotídea/diagnóstico por imagen , Cuidados Críticos , Ecoencefalografía , Servicio de Urgencia en Hospital , Aneurisma Intracraneal/diagnóstico por imagen , Accidente Cerebrovascular/diagnóstico por imagen , Ultrasonografía , Insuficiencia Vertebrobasilar/diagnóstico por imagen , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/terapia , Disección de la Arteria Carótida Interna/diagnóstico por imagen , Disección de la Arteria Carótida Interna/terapia , Estenosis Carotídea/terapia , Hemorragia Cerebral/diagnóstico por imagen , Hemorragia Cerebral/terapia , Diagnóstico Diferencial , Humanos , Aneurisma Intracraneal/terapia , Monitoreo Fisiológico , Sensibilidad y Especificidad , Accidente Cerebrovascular/terapia , Trombectomía , Terapia Trombolítica , Ultrasonografía Doppler en Color , Ultrasonografía Doppler Transcraneal , Ultrasonografía Intervencional , Insuficiencia Vertebrobasilar/terapiaRESUMEN
Intracerebral hemorrhage (ICH) is the most devastating form of stroke. It affects approximately 2 million people worldwide every year and is a major cause of mortality and morbidity. Despite the focus of intensive scientific research on ICH for decades there is still no proven treatment strategy for this disease. Advances in knowledge on the underlying pathomechanisms of ICH and the clinical impact have contributed to the development of novel treatment approaches. Currently, surgical treatment, aggressive blood pressure management and intraventricular fibrinolysis in patients with additional severe intraventricular hemorrhage are being investigated in large scale phase III clinical trials.
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Antihipertensivos/uso terapéutico , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/terapia , Cuidados Críticos/métodos , Fibrinolíticos/uso terapéutico , Procedimientos Neuroquirúrgicos/métodos , HumanosRESUMEN
Several acute stroke trials are underway or have been recently completed. Among the latter are the ICTUS trial and the IST-3 trial. Several other approaches are being tested for thrombolytic therapy among them modern imaging-based patient selection and new thrombolytic agents, such as desmoteplase and tenecteplase. Other strategies include neuroprotection and neurorestoration, biophysical approaches, such as near infrared laser therapy, hemodynamic augmentation and sphenopalatine ganglion stimulation. Mechanical thrombectomy is practiced in many centers although randomized trials are pending and the IMS-3 trial was stopped. This overview will cover the very recently completed and currently recruiting acute ischemic stroke trials.
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Isquemia Encefálica/economía , Isquemia Encefálica/terapia , Ensayos Clínicos como Asunto/economía , Sector de Atención de Salud/economía , Hipotermia Inducida/métodos , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/complicaciones , Femenino , Alemania , Costos de la Atención en Salud , Humanos , Hipotermia Inducida/economía , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/etiología , Adulto JovenRESUMEN
Near-infrared laser therapy (NIRLT) as a transcranial laser therapy (TLT) is currently being investigated as a neuroreparatory and neuroprotective treatment for acute ischemic stroke patients in a pivotal phase III trial (NEST-3). In this review we cover the theoretical background, experimental studies, translational research and the clinical trial program.
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Isquemia Encefálica/prevención & control , Isquemia Encefálica/rehabilitación , Terapia por Láser/métodos , Rehabilitación de Accidente Cerebrovascular , Accidente Cerebrovascular/prevención & control , Isquemia Encefálica/etiología , Humanos , Rayos Infrarrojos/uso terapéutico , Accidente Cerebrovascular/etiologíaRESUMEN
Transcranial B-mode sonography is an easy to use bedside imaging modality to monitor significant changes of the brain parenchyma such as in malignant middle cerebral infarction or intracerebral hemorrhage. The elevation of intracranial pressure can be followed with various neurosonographical techniques: Measurements of the ventricular width, midline shift, arterial resistance, and optic nerve sheath diameter. They should be viewed as complementary to each other and to other imaging modalities. Repeated cCT and MRI may be avoided in unstable patients by bedside neurosonography in the hands of an experienced physician. Monitoring of evolving hydrocephalus using serial measurements of the third and lateral ventricles can be used to guide therapeutic decisions such as the removal of a ventricular drainage. The cessation of cerebral blood flow in the case of intracranial pressure exceeding systemic arterial pressure is an important part of brain death diagnostics. Early demonstration of a sufficient temporal bone window is needed in patients in whom brain death may be expected. Cerebrovascular autoregulation is an integer component of the brain's blood supply and is compromised in a variety of neurological diseases. In neurological/neurosurgical patients in the intensive care unit, its assessment allows for extended neuromonitoring and control of therapeutic procedures.