Dual antiplatelet Use for extended period taRgeted to AcuTe ischemic stroke with presumed atherosclerotic OrigiN (DURATION) trial: Rationale and design.

RATIONALE: The optimal duration of dual antiplatelet therapy (DAPT) with clopidogrel-aspirin for the large artery atherosclerotic (LAA) stroke subtype has been debated. AIMS: To determine whether the 1-year risk of recurrent vascular events could be reduced by a longer duration of DAPT in patients with the LAA stroke subtype. METHODS AND STUDY DESIGN: A total of 4806 participants will be recruited to detect a statistically significant relative risk reduction of 22% with 80% power and a two-sided alpha error of 0.05, including a 10% loss to follow-up. This is a registry-based, multicenter, prospective, randomized, open-label, blinded end point study designed to evaluate the efficacy and safety of a 12-month duration of DAPT compared with a 3-month duration of DAPT in the LAA stroke subtype. Patients will be randomized (1:1) to either DAPT for 12 months or DAPT for 3 months, followed by monotherapy (either aspirin or clopidogrel) for the remaining 9 months. STUDY OUTCOMES: The primary efficacy outcome of the study is a composite of stroke (ischemic or hemorrhagic), myocardial infarction, and all-cause mortality for 1 year after the index stroke. The secondary efficacy outcomes are (1) stroke, (2) ischemic stroke or transient ischemic attack, (3) hemorrhagic stroke, and (4) all-cause mortality. The primary safety outcome is major bleeding. DISCUSSION: This study will help stroke physicians determine the appropriate duration of dual therapy with clopidogrel-aspirin for patients with the LAA stroke subtype. TRIAL REGISTRATION: URL: https://cris.nih.go.kr/cris. CRIS Registration Number: KCT0004407.

A multicenter study of altered level of consciousness in the emergency room.

New-onset altered level of consciousness (ALC) is a challenge in real-world clinical practice. Although its presentation is nonspecific and its etiology is intricate, the term ALC is frequently used in the emergency room (ER). This study aimed to clarify and classify the etiologies and outcomes of the ALC in the ER. We retrospectively investigated ALC patients in the ER of four tertiary referral centers from February 2018 to January 2020. The etiology of ALC was comprehensively analyzed by a consortium of university professors, board-certified clinicians in neurology, emergency medicine, or internal medicine. The time point to determine the etiology of ALC was at the time of discharge from the ER. A total of 315,526 patients who visited ER due to ALC were reviewed and found 7988 eligible patients, of which 4298 (53.8%) were male and 5282 (66.1%) were older than 60. The overall mortality was 13.5%. Except undetermined, the 9 etiologies (n = 7552) were categorized into extra- (n = 4768, 63.1%) or intracranial etiology (n = 2784, 36.9%). The most common etiology of ALC in the ER was metabolic cause (n = 1972, 24.7%), followed by systemic infection (n = 1378, 17.3%). The majority of ALC in the ER was derived from extracranial etiology. ALC in the ER is a neurological manifestation of diverse etiologies; not all can be confirmed in the ER. Not only neurological but also critical systemic illnesses should be considered to assess the protean manifestations of ALC in the ER.

Emergency Cervical Carotid Artery Stenting After Intravenous Thrombolysis in Patients With Hyperacute Ischemic Stroke.

BACKGROUND: Intravenous recombinant tissue plasminogen activator (IV rtPA) is the mainstay of treatment for acute ischemic stroke to recanalize thrombosed intracranial vessels within 4.5 hours. Emergency carotid artery stenting for the treatment of acute stroke due to steno-occlusion of the proximal internal carotid artery (ICA) can improve symptoms, prevent neurological deterioration, and reduce recurrent stroke risk. The feasibility and safety of the combination therapy of IV rtPA and urgent carotid artery stenting have not been established. METHODS: From November 2005 to October 2020, we retrospectively assessed patients who had undergone emergent carotid artery stenting after IV rtPA for hyperacute ischemic stroke due to steno-occlusive proximal ICA lesion. Hemorrhagic transformation, successful recanalization, modified Rankin Scale (mRS) score at 90 days, and stent patency at 3 and 12 months or longer were evaluated. Favorable outcome was defined as a 90-days mRS score of ≤ 2. RESULTS: Nineteen patients with hyperacute stroke had undergone emergent carotid artery stenting after IV rtPA therapy. Their median age was 70 (67.5-73.5) years (94.7% men). Among 15 patients with an additional intracranial occlusion after flow restoration in the proximal ICA, a modified TICI grade ≥ 2b was achieved in 11 patients (73.3%). Hemorrhagic transformation occurred in five patients (26.3%); mortality rate was 5.7%. Eleven patients (57.9%) had favorable outcomes at 90 days. Stent patients (94.1%) maintained stent patency for ≥ 12 months. CONCLUSION: We showed that emergent carotid artery stenting after IV rtPA therapy for hyperacute stroke caused by atherosclerotic proximal ICA steno-occlusion was feasible and safe.

Etiologies of altered level of consciousness in the emergency room.

Altered levels of consciousness (ALCs) is a challenging issue; however, data describing its etiology and frequency are lacking. This study aimed to clarify and classify the etiologies of ALCs in the emergency room (ER) and to evaluate their destinations and the form of discharge. This retrospective study included patients with an ALC who visited the ER of a university hospital between January 2018 and December 2020. The cause and classification of the ALCs were carefully determined by a consortium of board-certified faculty members in emergency medicine, internal medicine, and neurology. The reference point for determining the etiology of ALC was discharge from the ER. In total, 2028 patients with ALCs were investigated. More than half (1037, 51.1%) visited the ER between 9:00 and 18:00. The most common etiology was systemic infection (581, 28.6%), followed by metabolic causes (455, 22.4%), and stroke (271, 13.4%). The two leading etiologies were extracranial and had a majority of the cases (1036, 51.5%). The overall mortality rate was 17.2%. This study provides fundamental information on ALC in the ER. Although intracranial etiologies have been foregrounded, this study demonstrated that extracranial etiologies are the main cause of ALC in the ER.

Clinical Implications of Neurological Comorbidities and Complications in ICU Patients with COVID-19.

Clinical implications of neurological problems during intensive care unit (ICU) care for coronavirus disease 2019 (COVID-19) patients are unknown. This study aimed to describe the clinical implications of preexisting neurological comorbidities and new-onset neurological complications in ICU patients with COVID-19. ICU patients who were isolated and treated for COVID-19 between 19 February 2020 and 3 May 2020, from one tertiary hospital and one government-designated branch hospital were included. Clinical data including previous neurological disorders were extracted from electronic medical records. All neurological complications were evaluated by neurointensivists. Multiple logistic regression analysis was performed to investigate independent factors in ICU mortality. The median age of 52 ICU patients with COVID-19 was 73 years. Nineteen (36.5%) patients had preexisting neurological comorbidities, and new-onset neurological complications occurred in 23 (44.2%) during ICU admission. Patients with preexisting neurological comorbidities required tracheostomy more frequently and more ventilator and ICU days than those without. Patients with new-onset neurological complications experienced more medical complications and had higher ICU severity score and ICU mortality rates. New-onset neurological complications remained an independent factor for ICU mortality. Many COVID-19 patients in the ICU have preexisting neurological comorbidities, making them at a high risk of new-onset neurological complications.

Clinical prognosis of isolated anterior cerebral artery territory infarction: a retrospective study.

BACKGROUND: Isolated anterior cerebral artery territory (ACA) infarction is a rare phenomenon, and is known to have distinctive clinical features. Little is known regarding the clinical prognosis of isolated ACA territory infarction with associated factors, and its impact on dwelling and job status. We investigated the short- and long-term outcomes of anterior cerebral artery (ACA) territory infarction, and the associated factors involved in the development of the distinctive symptoms. METHODS: This retrospective study in a prospective cohort of acute ischaemic stroke patients included consecutively enrolled patients with isolated ACA territory infarction. We investigated the functional status using the modified Rankin scale (mRS) score at discharge, three months' post-discharge, and one-year post-discharge. We also investigated the occlusion site of the ACA (proximal vs. distal); presence of distinctive symptoms of ACA territory infarction including behaviour changes, indifference, aphasia, and urinary incontinence; and the effect of these symptoms on dwelling and job status one year after discharge. RESULTS: Between April 2014 and March 2019, 47 patients with isolated ACA territory infarction were included. Twenty-nine patients (61.7 %) had good outcomes (mRS ≤ 2) at discharge; however, the mRS score increased at three months (40; 85.1 %, p < 0.001) and one year (41; 87.2 %) post-discharge. Occlusion of the ACA proximal segment was independently associated with the development of distinctive symptoms (adjusted odds ratio, 17.68; 95 % confidence interval: 2.55-122.56, p < 0.05). Twenty-one (48.8 %) patients with good outcomes at one year experienced a change in dwelling status and job loss; 20 (95.2 %) of them had distinctive ACA territory symptoms with proximal ACA occlusion. CONCLUSIONS: Short- and long-term outcomes of isolated ACA territory infarction were favourable. However, proximal segment occlusion was associated with the development of distinctive symptoms, possibly related to future dwelling and job status.

Impact of statin pretreatment on the complications of carotid stenting in asymptomatic patients: observational study.

BACKGROUND: Carotid stenosis is a known risk factor for ischemic stroke, and carotid artery stenting is an effective preventive procedure. However, the stroke risk reduction for asymptomatic patients is small. Therefore, it is important to reduce the risk of complications, particularly in asymptomatic carotid stenosis. Statins are known to reduce the overall risk of periprocedural complications, although there is a lack of data focusing on asymptomatic patients. We aimed to investigate whether different doses of statin pretreatment can reduce periprocedural complications of carotid artery stenting (CAS) in patients with asymptomatic carotid artery stenosis. METHODS: Between July 2003 and June 2013, 276 consecutive patients received CAS for asymptomatic carotid stenosis. Periprocedural complications included the outcome of stroke, myocardial infarction, or death within 30 days of CAS. Statin pretreatment was categorized as no-statin (n = 87, 31.5%), standard-dose (< 40 mg, n = 139, 50.4%), and high-dose statin (≥40 mg, n = 50, 18.1%) according to the atorvastatin equivalent dose. The Cochran-Armitage (CA) trend test was performed to investigate the association of periprocedural complications with statin dose. RESULTS: The overall periprocedural complication rate was 3.3%. There was no significant difference in the risk of periprocedural complications between the three groups (no statin: n = 3 [3.4%]; standard-dose: n = 4 [2.9%]; high-dose n = 2 [4.0%] p = 0.923). The CA trend test did not demonstrate a trend in the proportion of periprocedural complications across increasing statin equivalent doses (p = 0.919). CONCLUSIONS: Statin pretreatment before CAS showed neither absolute nor dose-dependent effects against periprocedural complications in asymptomatic patients undergoing CAS.

The Length of an Infarcted Lesion Along the Perforating Artery Predicts Neurological Deterioration in Single Subcortical Infarction Without Any Relevant Artery Stenosis.

Objectives: This study aimed to assess image biomarkers of early neurological deterioration in single subcortical infarction (SSI) without any relevant artery stenosis. Methods: Between June 2005 and December 2009, consecutive patients with SSI within 24 h of symptom onset were enrolled. Magnetic resonance angiography of the brain and neck was obtained from all patients to confirm the absence of any stenosis of relevant arteries. We defined early neurological deterioration (END) as neurological worsening by ≥ 2 points based on the initial National Institutes of Health Stroke Scale score during the first week post admission or prior to hospital discharge. A multiple logistic regression analysis was used to evaluate the independent predictors of END in SSI. Results: A total of 205 patients (109 males; aged 63.9 ± 11.0 years, range 39-90 years) were enrolled, of whom 158 (77%) remained stable or improved, while 47 (23%) showed neurological worsening. There were significant differences in the maximum diameter of the largest area on an axial view and in the number of slices showing cerebral infarction on a transverse plane between patients with and without END. A adjusting for age, hypercholesterolemia, hemoglobin, NIHSS on admission and these magnetic resonance imaging characteristics, the occurrence of having three or more slices showing the cerebral infarction on a transverse plane was an independent predictor of END in SSI without relevant artery stenosis (1 vs. 3; OR 14.281; 95% CI 1.76-115.8; p = 0.013, 1 vs. 4; OR 14.04; 95% CI 1.65-119.57; p = 0.016). Conclusion: The longitudinal length of the infarcted lesion along the perforating artery predicts END in cases of acute SSI without any relevant artery stenosis.

Characteristics of Acute Stroke in Patients with Coronavirus Disease 2019 and Challenges in Stroke Management during an Epidemic.

Coronavirus disease 2019 (COVID-19) is an ongoing pandemic infection associated with high morbidity and mortality. The Korean city of Daegu endured the first large COVID-19 outbreak outside of China. Since the report of the first confirmed case in Daegu on February 18, 2020, a total of 6,880 patients have been reported until May 29, 2020. We experienced five patients with ischemic stroke and COVID-19 during this period in four tertiary hospitals in Daegu. The D-dimer levels were high in all three patients in whom D-dimer blood testing was performed. Multiple embolic infarctions were observed in three patients and suspected in one. The mean time from stroke symptom onset to emergency room arrival was 22 hours. As a result, acute treatment for ischemic stroke was delayed. The present case series report raises the possibility that the coronavirus responsible for COVID-19 causes or worsens stroke, perhaps by inducing inflammation. The control of COVID-19 is very important; however, early and proper management of stroke should not be neglected during the epidemic.