Showing papers in "Stroke in 2014"
TL;DR: The incidence of stroke is likely to continue to escalate because of an expanding population of elderly Americans; a growing epidemic of diabetes, obesity, and physical inactivity among the general population; and a greater prevalence of heart failure patients.
Abstract: Purpose—This scientific statement provides an overview of the evidence on physical activity and exercise recommendations for stroke survivors. Evidence suggests that stroke survivors experience phy...
1,130 citations
TL;DR: This guideline focuses on the risk factors unique to women, such as reproductive factors, and those that are more common in women, including migraine with aura, obesity, metabolic syndrome, and atrial fibrillation, which believe a female-specific stroke risk score is warranted.
Abstract: Purpose— The aim of this statement is to summarize data on stroke risk factors that are unique to and more common in women than men and to expand on the data provided in prior stroke guidelines and cardiovascular prevention guidelines for women. This guideline focuses on the risk factors unique to women, such as reproductive factors, and those that are more common in women, including migraine with aura, obesity, metabolic syndrome, and atrial fibrillation. Methods— Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council’s Scientific Statement Oversight Committee and the AHA’s Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through May 15, 2013. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. Results— We provide current evidence, research gaps, and recommendations on risk of stroke related to preeclampsia, oral contraceptives, menopause, and hormone replacement, as well as those risk factors more common in women, such as obesity/metabolic syndrome, atrial fibrillation, and migraine with aura. Conclusions— To more accurately reflect the risk of stroke in women across the lifespan, as well as the clear gaps in current risk scores, we believe a female-specific stroke risk score is warranted.
755 citations
TL;DR: There is strong evidence that the decline in stroke mortality can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension.
Abstract: Background and Purpose—Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden. Methods—Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. Results—The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although
660 citations
Tohoku University1, Kyoto University2, Chiba University3, Gifu University4, Gunma University5, Hokkaido University6, Iwate Medical University7, Kitasato University8, Nagasaki University9, Nagoya City University10, Memorial Hospital of South Bend11, Nara Medical University12, Fukuoka University13, Tenri Hospital14, University of Tokushima15
TL;DR: Although statistically marginal, Kaplan–Meier analysis revealed the significant difference between surgical and nonsurgical group, suggesting the preventive effect of direct bypass against rebleeding.
Abstract: Background and purpose About one half of those who develop adult-onset moyamoya disease experience intracranial hemorrhage. Despite the extremely high frequency of rebleeding attacks and poor prognosis, measures to prevent rebleeding have not been established. The purpose of this study is to determine whether extracranial-intracranial bypass can reduce incidence of rebleeding and improve patient prognosis. Methods This study was a multicentered, prospective, randomized, controlled trial conducted by 22 institutes in Japan. Adult patients with moyamoya disease who had experienced intracranial hemorrhage within the preceding year were given either conservative care or bilateral extracranial-intracranial direct bypass and were observed for 5 years. Primary and secondary end points were defined as all adverse events and rebleeding attacks, respectively. Results Eighty patients were enrolled (surgical, 42; nonsurgical, 38). Adverse events causing significant morbidity were observed in 6 patients in the surgical group (14.3%) and 13 patients in the nonsurgical group (34.2%). Kaplan-Meier survival analysis revealed significant differences between the 2 groups (3.2%/y versus 8.2%/y; P=0.048). The hazard ratio of the surgical group calculated by Cox regression analysis was 0.391 (95% confidence interval, 0.148-1.029). Rebleeding attacks were observed in 5 patients in the surgical group (11.9%) and 12 in the nonsurgical group (31.6%), significantly different in the Kaplan-Meier survival analysis (2.7%/y versus 7.6%/y; P=0.042). The hazard ratio of the surgical group was 0.355 (95% confidence interval, 0.125-1.009). Conclusions Although statistically marginal, Kaplan-Meier analysis revealed the significant difference between surgical and nonsurgical group, suggesting the preventive effect of direct bypass against rebleeding. Clinical trial registration url http://www.umin.ac.jp/ctr/index.htm. Unique identifier: C000000166.
484 citations
TL;DR: Increased time scheduled for therapy was a significant predictor of increased improvement by itself and when controlling for linear and quadratic effects of time after stroke, suggesting that large doses of therapy lead to clinically meaningful improvements, controlling for time after Stroke.
Abstract: Background and Purpose— Neurophysiological models of rehabilitation and recovery suggest that a large volume of specific practice is required to induce the neuroplastic changes that underlie behavioral recovery. The primary objective of this meta-analysis was to explore the relationship between time scheduled for therapy and improvement in motor therapy for adults after stroke by (1) comparing high doses to low doses and (2) using metaregression to quantify the dose–response relationship further. Methods— Databases were searched to find randomized controlled trials that were not dosage matched for total time scheduled for therapy. Regression models were used to predict improvement during therapy as a function of total time scheduled for therapy and years after stroke. Results— Overall, treatment groups receiving more therapy improved beyond control groups that received less ( g =0.35; 95% confidence interval, 0.26–0.45). Furthermore, increased time scheduled for therapy was a significant predictor of increased improvement by itself and when controlling for linear and quadratic effects of time after stroke. Conclusions— There is a positive relationship between the time scheduled for therapy and therapy outcomes. These data suggest that large doses of therapy lead to clinically meaningful improvements, controlling for time after stroke. Currently, trials report time scheduled for therapy as a measure of therapy dose. Preferable measures of dose would be active time in therapy or repetitions of an exercise.
469 citations
TL;DR: This scientific statement addresses the early approach to the patient with a swollen ischemic stroke in a cerebral or cerebellar hemisphere and classifies the level of certainty and the class and level of evidence.
Abstract: Background and Purpose—There are uncertainties surrounding the optimal management of patients with brain swelling after an ischemic stroke. Guidelines are needed on how to manage this major complication, how to provide the best comprehensive neurological and medical care, and how to best inform families facing complex decisions on surgical intervention in deteriorating patients. This scientific statement addresses the early approach to the patient with a swollen ischemic stroke in a cerebral or cerebellar hemisphere. Methods—The writing group used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. The panel reviewed the most relevant articles on adults through computerized searches of the medical literature using MEDLINE, EMBASE, and Web of Science through March 2...
413 citations
TL;DR: Recurrent stroke rate in this study was lower compared with those of previous clinical trials but remains unacceptably high in a subgroup of patients with severe stenosis.
Abstract: Background and Purpose— We aimed to establish the prevalence, characteristics, and outcomes of intracranial atherosclerosis (ICAS) in China by a large, prospective, multicenter study.
Methods— We evaluated 2864 consecutive patients who experienced an acute cerebral ischemia <7 days after symptom onset in 22 Chinese hospitals. All patients underwent magnetic resonance angiography, with measurement of diameter of the main intracranial arteries. ICAS was defined as ≥50% diameter reduction on magnetic resonance angiography.
Results— The prevalence of ICAS was 46.6% (1335 patients, including 261 patients with coexisting extracranial carotid stenosis). Patients with ICAS had more severe stroke at admission and stayed longer in hospitals compared with those without intracranial stenosis (median National Institutes of Health Stroke Scale score, 3 versus 5; median length of stay, 14 versus 16 days; both P <0.0001). After 12 months, recurrent stroke occurred in 3.27% of patients with no stenosis, in 3.82% for those with 50% to 69% stenosis, in 5.16% for those with 70% to 99% stenosis, and in 7.27% for those with total occlusion. Cox proportional hazards regression analyses showed that the degree of arterial stenosis, age, family history of stroke, history of cerebral ischemia or heart disease, complete circle of Willis, and National Institutes of Health Stroke Scale score at admission were independent predictors for recurrent stroke at 1 year. The highest rate of recurrence was observed in patients with occlusion with the presence of ≥3 additional risk factors.
Conclusions— ICAS is the most common vascular lesion in patients with cerebrovascular disease in China. Recurrent stroke rate in our study was lower compared with those of previous clinical trials but remains unacceptably high in a subgroup of patients with severe stenosis.
409 citations
TL;DR: The RACE scale is a simple tool that can accurately assess stroke severity and identify patients with acute stroke with large artery occlusion at prehospital setting by medical emergency technicians.
Abstract: Background and Purpose—We aimed to develop and validate a simple prehospital stroke scale to predict the presence of large vessel occlusion (LVO) in patients with acute stroke. Methods—The Rapid Arterial oCclusion Evaluation (RACE) scale was designed based on the National Institutes of Health Stroke Scale (NIHSS) items with a higher predictive value of LVO on a retrospective cohort of 654 patients with acute ischemic stroke: facial palsy (scored 0–2), arm motor function (0–2), leg motor function (0–2), gaze (0–1), and aphasia or agnosia (0–2). Thereafter, the RACE scale was validated prospectively in the field by trained medical emergency technicians in 357 consecutive patients transferred by Emergency Medical Services to our Comprehensive Stroke Center. Neurologists evaluated stroke severity at admission and LVO was diagnosed by transcranial duplex, computed tomography, or MR angiography. Receiver operating curve, sensitivity, specificity, and global accuracy of the RACE scale were analyzed to evaluate i...
357 citations
TL;DR: In this article, a systematic review and meta-analysis was conducted to determine the frequency of newly detected atrial fibrillation using noninvasive or invasive cardiac monitoring after stroke or transient ischemic attack.
Abstract: Background and Purpose—Atrial fibrillation (AF) confers a high risk of recurrent stroke, although detection methods and definitions of paroxysmal AF during screening vary. We therefore undertook a systematic review and meta-analysis to determine the frequency of newly detected AF using noninvasive or invasive cardiac monitoring after ischemic stroke or transient ischemic attack. Methods—Prospective observational studies or randomized controlled trials of patients with ischemic stroke, transient ischemic attack, or both, who underwent any cardiac monitoring for a minimum of 12 hours, were included after electronic searches of multiple databases. The primary outcome was detection of any new AF during the monitoring period. We prespecified subgroup analysis of selected (prescreened or cryptogenic) versus unselected patients and according to duration of monitoring. Results—A total of 32 studies were analyzed. The overall detection rate of any AF was 11.5% (95% confidence interval, 8.9%–14.3%), although the ti...
333 citations
Ludwig Maximilian University of Munich1, University of Lübeck2, Harvard University3, deCODE genetics4, University of Maryland, Baltimore5, Stanford University6, University of Newcastle7, National Institutes of Health8, Boston University9, University of Washington10, Synlab Group11, Mayo Clinic12, Erasmus University Rotterdam13, University of Ottawa14, University of Iceland15, Broad Institute16, University of Edinburgh17, University of Pennsylvania18, Imperial College London19, Clinical Trial Service Unit20, Wellcome Trust Centre for Human Genetics21, University of Oxford22, Technische Universität München23, St George's, University of London24, University of Leicester25
TL;DR: In this article, the authors conducted a genome-wide analysis to evaluate the extent of shared genetic determination of the two diseases and found substantial overlap in the genetic risk of IS and particularly the LAS subtype with CAD.
Abstract: BACKGROUND AND PURPOSE: Ischemic stroke (IS) and coronary artery disease (CAD) share several risk factors and each has a substantial heritability. We conducted a genome-wide analysis to evaluate the extent of shared genetic determination of the two diseases. METHODS: Genome-wide association data were obtained from the METASTROKE, Coronary Artery Disease Genome-wide Replication and Meta-analysis (CARDIoGRAM), and Coronary Artery Disease (C4D) Genetics consortia. We first analyzed common variants reaching a nominal threshold of significance (P<0.01) for CAD for their association with IS and vice versa. We then examined specific overlap across phenotypes for variants that reached a high threshold of significance. Finally, we conducted a joint meta-analysis on the combined phenotype of IS or CAD. Corresponding analyses were performed restricted to the 2167 individuals with the ischemic large artery stroke (LAS) subtype. RESULTS: Common variants associated with CAD at P<0.01 were associated with a significant excess risk for IS and for LAS and vice versa. Among the 42 known genome-wide significant loci for CAD, 3 and 5 loci were significantly associated with IS and LAS, respectively. In the joint meta-analyses, 15 loci passed genome-wide significance (P<5×10(-8)) for the combined phenotype of IS or CAD and 17 loci passed genome-wide significance for LAS or CAD. Because these loci had prior evidence for genome-wide significance for CAD, we specifically analyzed the respective signals for IS and LAS and found evidence for association at chr12q24/SH2B3 (PIS=1.62×10(-7)) and ABO (PIS=2.6×10(-4)), as well as at HDAC9 (PLAS=2.32×10(-12)), 9p21 (PLAS=3.70×10(-6)), RAI1-PEMT-RASD1 (PLAS=2.69×10(-5)), EDNRA (PLAS=7.29×10(-4)), and CYP17A1-CNNM2-NT5C2 (PLAS=4.9×10(-4)). CONCLUSIONS: Our results demonstrate substantial overlap in the genetic risk of IS and particularly the LAS subtype with CAD.
317 citations
TL;DR: SAH and acute ischemic stroke significantly impair the glymphatic system perfusion, and injection of tissue-type plasminogen activator either intracerebroventricularly to clear perivascular spaces (for SAH) or intravenously to restore arterial patency (for isChemic stroke) may improve Glymphatic function.
Abstract: Background and Purpose—The aim of the present study was to investigate the impact of different stroke subtypes on the glymphatic system using MRI. Methods—We first improved and characterized an in vivo protocol to measure the perfusion of the glymphatic system using MRI after minimally invasive injection of a gadolinium chelate within the cisterna magna. Then, the integrity of the glymphatic system was evaluated in 4 stroke models in mice including subarachnoid hemorrhage (SAH), intracerebral hemorrhage, carotid ligature, and embolic ischemic stroke. Results—We were able to reliably evaluate the glymphatic system function using MRI. Moreover, we provided evidence that the glymphatic system was severely impaired after SAH and in the acute phase of ischemic stroke, but was not altered after carotid ligature or in case of intracerebral hemorrhage. Notably, this alteration in glymphatic perfusion reduced brain clearance rate of low-molecular-weight compounds. Interestingly, glymphatic perfusion after SAH can ...
TL;DR: Realistically achievable small reductions in stroke thrombolysis delays would result in significant and robust average health benefits over patients’ lifetimes, and the awareness of concrete importance of speed could promote practice change.
Abstract: Background and Purpose— Stroke thrombolysis is highly time-critical, but data on long-term effects of small reductions in treatment delays have not been available. Our objective was to quantify patient lifetime benefits gained from faster treatment. Methods— Observational prospective data of consecutive stroke patients treated with intravenous thrombolysis in Australian and Finnish centers (1998–2011; n=2258) provided distributions of age, sex, stroke severity, onset-to-treatment times, and 3-month modified Rankin Scale in daily clinical practice. Treatment effects derived from a pooled analysis of thrombolysis trials were used to model the shift in 3-month modified Rankin Scale distributions with reducing treatment delays, from which we derived the expected lifetime and level of long-term disability with faster treatment. Results— Each minute of onset-to-treatment time saved granted on average 1.8 days of extra healthy life (95% prediction interval, 0.9–2.7). Benefit was observed in all groups: each minute provided 0.6 day in old severe (age, 80 years; National Institutes of Health Stroke Scale [NIHSS] score, 20) patients, 0.9 day in old mild (age, 80 years; NIHSS score, 4) patients, 2.7 days in young mild (age, 50 years; NIHSS score, 4) patients, and 3.5 days in young severe (age, 50 years; NIHSS score, 20) patients. Women gained slightly more than men over their longer lifetimes. In the whole cohort, each 15 minute decrease in treatment delay provided an average equivalent of 1 month of additional disability-free life. Conclusions— Realistically achievable small reductions in stroke thrombolysis delays would result in significant and robust average health benefits over patients’ lifetimes. The awareness of concrete importance of speed could promote practice change.
TL;DR: The data from the largest endovascular trial to date suggest that collaterals are an important consideration in future trial design, and more robust collateral grade was associated with better recanalization, reperfusion, and subsequent better clinical outcomes.
Abstract: Background and Purpose—Endovascular strategies provide unique opportunity to correlate angiographic measures of collateral circulation at the time of endovascular therapy. We conducted systematic analyses of collaterals at conventional angiography on recanalization, reperfusion, and clinical outcomes in the endovascular treatment arm of the Interventional Management of Stroke (IMS) III trial. Methods—Prospective evaluation of angiographic collaterals was conducted via central review of subjects treated with endovascular therapy in IMS III (n=331). Collateral grade before endovascular therapy was assessed with the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale, blinded to all other data. Statistical analyses investigated the association between collaterals with baseline clinical variables, angiographic measures of recanalization, reperfusion and clinical outcomes. Results—Adequate views of collateral circulation to the ischemic territory were ava...
TL;DR: Access to nationwide register data shows that AF is more common among patients with ischemic stroke than those previously reported, and the likelihood for underlying AF was strongly correlated to the CHA2DS2-VASC score, which is a point based scheme for assessment of stroke risk but which also predicts likelihood of AF.
Abstract: Background and Purpose-Atrial fibrillation (AF) is a common cause of devastating but potentially preventable stroke. Estimates of the prevalence of AF among patients with stroke vary considerably b ...
TL;DR: Addressing the palliative care needs of patients and families throughout the course of illness can complement existing practices and improve the quality of life of stroke patients, their families, and their care providers.
Abstract: Background and Purpose—The purpose of this statement is to delineate basic expectations regarding primary palliative care competencies and skills to be considered, learned, and practiced by provide...
TL;DR: Results of this hitherto first randomized controlled trial indicate that intravenous infusion of BMSCs is safe, but there is no beneficial effect of treatment on stroke outcome.
Abstract: Background and purpose Pilot studies have suggested benefit from intravenous administration of bone marrow mononuclear stem cells (BMSCs) in stroke. We explored the efficacy and safety of autologous BMSCs in subacute ischemic stroke. Methods This was a phase II, multicenter, parallel group, randomized trial with blinded outcome assessment that included 120 patients. Patients with subacute ischemic stroke were randomly assigned to the arm that received intravenous infusion of autologous BMSCs or to control arm. Coprimary clinical efficacy outcomes were Barthel Index score and modified Rankin scale at day 180. Secondary outcomes were change in infarct volume, National Institute of Health Stroke Scale (NIHSS) at day 90 and 180. Main safety outcomes were adverse events, any new area of (18)fluorodeoxyglucose positron emission tomography uptake in any body part over 365 days. Results Fifty-eight patients received a mean of 280.75 million BMSCs at median of 18.5 days after stroke onset. There was no significant difference between BMSCs arm and control arm in the Barthel Index score (63.1 versus 63.6; P=0.92), modified Rankin scale shift analysis (P=0.53) or score >3 (47.5% versus 49.2%; P=0.85), NIHSS score (6.3 versus 7.0; P=0.53), change in infarct volume (-11.1 versus -7.36; P=0.63) at day 180. Adverse events were also similar in the 2 arms, and no patient showed any new area of (18)fluorodeoxyglucose uptake. Conclusions With the methods used, results of this hitherto first randomized controlled trial indicate that intravenous infusion of BMSCs is safe, but there is no beneficial effect of treatment on stroke outcome. Clinical trial registration URLs: http://ctri.nic.in/Clinicaltrials and http://www.clinicaltrials.gov. Unique identifiers: CTRI-ROVCTRI/2008/091/0004 and NCT0150177.
TL;DR: A tissue survival analysis suggests that prehospital rPerC may have immediate neuroprotective effects and future clinical trials should take such immediate effects, and their duration, into account.
Abstract: Background and Purpose—Remote ischemic preconditioning is neuroprotective in models of acute cerebral ischemia. We tested the effect of prehospital rPerC as an adjunct to treatment with intravenous alteplase in patients with acute ischemic stroke. Methods—Open-label blinded outcome proof-of-concept study of prehospital, paramedic-administered rPerC at a 1:1 ratio in consecutive patients with suspected acute stroke. After neurological examination and MRI, patients with verified stroke receiving alteplase treatment were included and received MRI at 24 hours and 1 month and clinical re-examination after 3 months. The primary end point was penumbral salvage, defined as the volume of the perfusion–diffusion mismatch not progressing to infarction after 1 month. Results—Four hundred forty-three patients were randomized after provisional consent, 247 received rPerC and 196 received standard treatment. Patients with a nonstroke diagnosis (n=105) were excluded from further examinations. The remaining patients had t...
TL;DR: Fruits and vegetables consumption are inversely associated with the risk of stroke, and citrus fruits, apples/pears, and leafy vegetables might contribute to the protection.
Abstract: Background and Purpose—We conducted a meta-analysis to summarize evidence from prospective cohort studies about the association of fruits and vegetables consumption with the risk of stroke. Methods—Pertinent studies were identified by a search of Embase and PubMed databases to January 2014. Study-specific relative risks with 95% confidence intervals were pooled using a random-effects model. Dose–response relationship was assessed by restricted cubic spline. Results—Twenty prospective cohort studies were included, involving 16 981 stroke events among 760 629 participants. The multivariable relative risk (95% confidence intervals) of stroke for the highest versus lowest category of total fruits and vegetables consumption was 0.79 (0.75–0.84), and the effect was 0.77 (0.71–0.84) for fruits consumption and 0.86 (0.79–0.93) for vegetables consumption. Subgroup and meta-regression showed that the inverse association of total fruits and vegetables consumption with the risk of stroke was consistent in subgroup an...
TL;DR: Almost 30% of all UIAs in people of working age ruptured during a lifelong follow-up, and the risk varied substantially on the basis of risk factor burden.
Abstract: Background and Purpose— Our aim was to define for the first time the lifelong natural course of unruptured intracranial aneurysms (UIAs) and identify high-risk and low-risk patients for the rupture.
Methods— One hundred and eighteen patients (61 women) with UIAs were diagnosed between 1956 and 1978 and followed up until death or subarachnoid hemorrhage (SAH). The median age at the diagnosis was 43.5 years (range, 22.6–60.7 years). The median size of the UIA at the diagnosis was 4 mm (range, 2–25 mm). Analyzed risk factors for a rupture included sex, age, cigarette smoking, systolic blood pressure values, diagnosed hypertension, UIA size, and number of UIAs.
Results— Thirty four (29%) out of 118 people had SAH during the lifelong follow-up. The median age at SAH was 51.3 years (range, 30.1–71.8 years). The annual rupture rate per patient was 1.6%. Female sex, current smoking, and aneurysm size of ≥7 mm in diameter were risk factors for a lifetime SAH. Depending on the risk factor burden, the lifetime risk of an aneurysmal SAH varied from 0% to 100%, and the annual rupture rate from 0% to 6.5%. Of the 96 patients with small (<7 mm) UIAs, 24 (25%) had an aneurysmal SAH during the follow-up.
Conclusions— Almost 30% of all UIAs in people of working age ruptured during a lifelong follow-up. The risk varied substantially on the basis of risk factor burden. Because even small UIAs ruptured, treatment decisions of UIAs should perhaps be based on the risk factor status.
Boston University1, Medical College of Wisconsin2, Emory University3, California Pacific Medical Center4, Baptist Memorial Hospital-Memphis5, Wayne State University6, West Virginia University7, Veterans Health Administration8, University of Kansas9, Baylor College of Medicine10, University of Texas Southwestern Medical Center11, Harvard University12, University of Louisville13, University of Texas at Austin14, Houston Methodist Hospital15, University of Missouri16
TL;DR: Use of a BGC with the Solitaire Flow Restoration device resulted in superior revascularization results, faster procedure times, decreased need for adjunctive therapy, and improved clinical outcome.
Abstract: Background and Purpose—Efficient and timely recanalization is an important goal in acute stroke endovascular therapy. Several studies demonstrated improved recanalization and clinical outcomes with the stent retriever devices compared with the Merci device. The goal of this study was to evaluate the role of the balloon guide catheter (BGC) and recanalization success in a substudy of the North American Solitaire Acute Stroke (NASA) registry. Methods—The investigator-initiated NASA registry recruited 24 clinical sites within North America to submit demographic, clinical, site-adjudicated angiographic, and clinical outcome data on consecutive patients treated with the Solitaire Flow Restoration device. BGC use was at the discretion of the treating physicians. Results—There were 354 patients included in the NASA registry. BGC data were reported in 338 of 354 patients in this subanalysis, of which 149 (44%) had placement of a BGC. Mean age was 67.3±15.2 years, and median National Institutes of Health Stroke Sc...
TL;DR: The expected association of hypertension with deep CMB and low cholesterol and APOE &egr;4 with lobar CMB was observed and statin use was independently associated with CMB risk.
Abstract: Background and Purpose—Cerebral microbleeds (CMBs) are associated with increased risk of stroke and poor cognition. Vascular risk factors and medications used for stroke prevention may increase the risk of CMB. We examined the prevalence of CMB and the association of these risk factors with CMB, postulating that risk factors for cerebral amyloid angiopathy would be associated with lobar CMB and markers of hypertensive vasculopathy with deep CMB. Methods—We include 1965 Framingham Original and Offspring participants (age, 66.5±11.0 years; 54% women) and evaluated the age- and sex-specific prevalence of CMB. We related various vascular and genetic (apolipoprotein E [APOE]) risk factors and medication use to the presence of CMB overall and stratified by brain location (deep, lobar, or mixed). Results—CMBs were observed in 8.8% of participants, being mostly lobar (63%). CMB prevalence increased with age (P<0.0001) and was higher in men (P<0.001). Hypertension increased risk of any CMB, and in deep and mixed l...
TL;DR: A critical analysis of 17 caregiver intervention studies and 15 caregiver/stroke survivor dyad intervention studies was conducted to provide evidence-based recommendations for the implementation and future design of stroke family caregiver and dyad interventions.
Abstract: Stroke is a leading cause of severe, long-term disability. Most stroke survivors are cared for in the home by a family caregiver. Caregiver stress is a leading cause of stroke survivor institutionalization, which results in significant costs to the healthcare system. Stroke family caregiver and dyad intervention studies have reported a variety of outcomes. A critical analysis of 17 caregiver intervention studies and 15 caregiver/stroke survivor dyad intervention studies was conducted to provide evidence-based recommendations for the implementation and future design of stroke family caregiver and dyad interventions.
TL;DR: CAWE was more frequently observed in unstable intracranial aneurysms and may be used as a surrogate of inflammatory activity in the aneurYSmal wall.
Abstract: Background and Purpose—Arterial wall enhancement on vessel wall MRI was described in intracranial inflammatory arterial disease. We hypothesized that circumferential aneurysmal wall enhancement (CAWE) could be an indirect marker of aneurysmal wall inflammation and, therefore, would be more frequent in unstable (ruptured, symptomatic, or undergoing morphological modification) than in stable (incidental and nonevolving) intracranial aneurysms. Methods—We prospectively performed vessel wall MRI in patients with stable or unstable intracranial aneurysms. Two readers independently had to determine whether a CAWE was present. Results—We included 87 patients harboring 108 aneurysms. Interreader and intrareader agreement for CAWE was excellent (κ=0.85; 95% confidence interval, 0.75–0.95 and κ=0.90; 95% confidence interval, 0.83–0.98, respectively). A CAWE was significantly more frequently seen in unstable than in stable aneurysms (27/31, 87% versus 22/77, 28.5%, respectively; P<0.0001). Multivariate logistic regr...
TL;DR: In the early days after ischemic stroke, information on structural brain damage from MRI supports prognosis of functional outcome as mentioned in this paper, which is rated widely by the modified Rankin Scale that correlates only moderately with lesion volume.
Abstract: Background and Purpose—In the early days after ischemic stroke, information on structural brain damage from MRI supports prognosis of functional outcome. It is rated widely by the modified Rankin Scale that correlates only moderately with lesion volume. We therefore aimed to elucidate the influence of lesion location from early MRI (days 2–3) on functional outcome after 1 month using voxel-based lesion symptom mapping. Methods—We analyzed clinical and MRI data of patients from a prospective European multicenter stroke imaging study (I-KNOW). Lesions were delineated on fluid-attenuated inversion recovery images on days 2 to 3 after stroke onset. We generated statistic maps of lesion contribution related to clinical outcome (modified Rankin Scale) after 1 month using voxel-based lesion symptom mapping. Results—Lesion maps of 101 patients with middle cerebral artery infarctions were included for analysis (right-sided stroke, 47%). Mean age was 67 years, median admission National Institutes of Health Stroke S...
TL;DR: HIR can be easily assessed on automatically processed perfusion maps and predicts the rate of collateral flow, infarct growth, and clinical outcome.
Abstract: Background and Purpose—We evaluate associations between the severity of magnetic resonance perfusion-weighted imaging abnormalities, as assessed by the hypoperfusion intensity ratio (HIR), on infarct progression and functional outcome in the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution Study 2 (DEFUSE 2). Methods—Diffusion-weighted magnetic resonance imaging and perfusion-weighted imaging lesion volumes were determined with the RAPID software program. HIR was defined as the proportion of TMax >6 s lesion volume with a Tmax >10 s delay and was dichotomized based on its median value (0.4) into low versus high subgroups as well as quartiles. Final infarct volumes were assessed at day 5. Initial infarct growth velocity was calculated as the baseline diffusion-weighted imaging (DWI) lesion volume divided by the delay from symptom onset to baseline magnetic resonance imaging. Total Infarct growth was determined by the difference between final infarct and baseline DWI volumes. Co...
TL;DR: Access of the US population to all facilities that actually provide intravenous r-tPA or endovascular therapy for acute ischemic stroke is described to provide a national perspective on acute stroke care and should inform the planning and optimization of stroke systems in the United States.
Abstract: Background and Purpose—Only 3% to 5% of patients with acute ischemic stroke receive intravenous recombinant tissue-type plasminogen activator (r-tPA) and <1% receive endovascular therapy. We describe access of the US population to all facilities that actually provide intravenous r-tPA or endovascular therapy for acute ischemic stroke. Methods—We used US demographic data and intravenous r-tPA and endovascular therapy rates in the 2011 US Medicare Provider and Analysis Review data set. International Classification of Diseases-Ninth Revision codes 433.xx, 434.xx and 436 identified acute ischemic stroke cases. International Classification of Diseases-Ninth Revision code 99.10 defined intravenous r-tPA treatment and International Classification of Diseases-Ninth Revision code 39.74 defined endovascular therapy. We estimated ambulance response times using arc-Geographic Information System’s network analyst and helicopter transport times using validated models. Population access to care was determined by summing...
Sir Charles Gairdner Hospital1, Duke University2, Stanford University3, Cardiovascular Institute of the South4, University of Münster5, Harvard University6, University of Cincinnati Academic Health Center7, Bayer HealthCare Pharmaceuticals8, Janssen Pharmaceutica9, Heidelberg University10, University of Edinburgh11
TL;DR: Among patients with atrial fibrillation treated with anticoagulation, the risk of ICH was higher among Asians, blacks, the elderly, and in those with previous stroke or transient ischemic attack, increased diastolic blood pressure, and reduced platelet count or serum albumin at baseline.
Abstract: Background and Purpose—Intracranial hemorrhage (ICH) is a life-threatening complication of anticoagulation. Methods—We investigated the rate, outcomes, and predictors of ICH in 14 264 patients with atrial fibrillation from Rivaroxaban Once Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF). Cox proportional hazards modeling was used. Results—During 1.94 years (median) of follow-up, 172 patients (1.2%) experienced 175 ICH events at a rate of 0.67% per year. The significant, independent predictors of ICH were race (Asian: hazard ratio, 2.02; 95% CI, 1.39–2.94; black: hazard ratio, 3.25; 95% CI, 1.43–7.41), age (1.35; 1.13–1.63 per 10-year increase), reduced serum albumin (1.39; 1.12–1.73 per 0.5 g/dL decrease), reduced platelet count below 210×109/L (1.08; 1.02–1.13 per 10×109/L decrease), previous stroke or transient ischemic attack (1.42; 1.02–1.96), and increased diastolic blood pressure (1.17; 1.01–1....
TL;DR: It is proposed that contrary to current opinion, preclinical stroke research can indeed predict clinical outcomes and phenotypes, and that there is little reason for nihilism.
Abstract: Stroke presents a major global burden to patients, their relatives, and whole economies.1 Worldwide intense efforts are being undertaken to understand the pathobiology of stroke and to develop novel, effective treatments. This has led to the discovery of a plethora of preclinically promising treatment strategies,2 but intravenous thrombolysis remains the only specific pharmacological treatment with proven efficacy in acute ischemic stroke.3 Apparently, of several hundred controlled clinical trials4 aiming to protect the brain against ischemia (neuroprotection) with compounds previously found effective in animal experiments, not a single one has led to the regulatory approval of a drug for this indication. Many pharmaceutical companies have, therefore, stopped developing treatments for this devastating disease, and nihilism is spreading in the field.
A roadblock seems to exist between bench and bedside, preventing the translation of highly effective preclinical neuroprotectants into the clinical realm.5 Despite the prevailing mantra of translational medicine,6 other fields report similar problems when making the preclinical-to-clinical transition. Much has been speculated about the reasons underlying the translational roadblock, and the phrase lost in translation has entered the titles of numerous biomedical publications.
In this article, we propose that contrary to current opinion, preclinical stroke research can indeed predict clinical outcomes and phenotypes. Numerous neuroprotectants were reported as lost in translation (Figure 1A), but there is reason to argue that the clinical trials were based on rather weak preclinical evidence, and that many pathophysiological principles and therapies were actually discovered in translation (Figure 1B). We propose that there is little reason for nihilism. We present a concise list of potential improvements that may help to reduce the current attrition rate of bench-to-bedside translation, even in neuroprotection. Stroke may even serve as a model disease because our analysis may apply to other fields where development of …
TL;DR: The aim of this review was to assess whether the multiple effects of exercise and physical activity correspond with the outcomes considered most important, by patients and carers, for life after stroke.
Abstract: Although stroke is now the fourth, not the third, most common cause of death in the United States,1 the burden of stroke has increased. Stroke is now the third (fifth in 1990) largest cause of disability-adjusted life years in the developed world.2 Around half of those who do survive stroke are permanently disabled.3
There are a wide range of poststroke problems, including movement and function, mobility, balance, cognition, attention, memory, pain, sensation, perception, emotional problems, and psychological issues. The physical and psychosocial consequences of stroke are complex and long term.
Longer-term problems are reported by stroke survivors 1 to 5 years post stroke. The most common include mobility (58%), fatigue (52%), concentration (45%), and falls (44%). Around half of those surviving report that their needs relating to these problems are not being met and this is higher among those who are more disabled.4
Addressing the long-term needs of people during life after stroke is a priority from both a service provision and a research perspective—many uncertainties remain on how best to address long-term post stroke problems.
The aim of this review was to assess whether the multiple effects of exercise and physical activity correspond with the outcomes considered most important, by patients and carers, for life after stroke.
Physical activity is defined as all human movement produced by the action of skeletal muscle that substantially increases energy expenditure. Physical activity is essential for improving and maintaining physical fitness. Exercise is a subset of physical activity that is planned, structured, and repetitive and is performed deliberately with the intention of improving physical fitness.5 Key indices of physical fitness include cardiorespiratory fitness and muscle strength and power; these determine our capacity to perform and tolerate physical activity.
Physical fitness is impaired after stroke. Cardiorespiratory fitness (![Graphic][1] peak) is …
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TL;DR: Because of lack of power, this trial was inconclusive and results should be taken as hypothesis generating.
Abstract: Background and Purpose—Severe atherosclerosis in the aortic arch is associated with a high risk of recurrent vascular events, but the optimal antithrombotic strategy is unclear. Methods—This prospective randomized controlled, open-labeled trial, with blinded end point evaluation (PROBE design) tested superiority of aspirin 75 to 150 mg/d plus clopidogrel 75 mg/d (A+C) over warfarin therapy (international normalized ratio 2–3) in patients with ischemic stroke, transient ischemic attack, or peripheral embolism with plaque in the thoracic aorta >4 mm and no other identified embolic source. The primary end point included cerebral infarction, myocardial infarction, peripheral embolism, vascular death, or intracranial hemorrhage. Follow-up visits occurred at 1 month and then every 4 months post randomization. Results—The trial was stopped after 349 patients were randomized during a period of 8 years and 3 months. After a median follow-up of 3.4 years, the primary end point occurred in 7.6% (13/172) and 11.3% (2...