[Does ECT raise the risk of a recurrent stroke?] / Vormt ECT een risico op een recidief van cerebrovasculair accident?

BACKGROUND: As the guidelines and evidence for the use of electroconvulsive therapy (ECT) in patients with a recent or past history of stroke are unclear, ECT tends to be avoided in this population. AIM: To give a systematic review the literature on the risk and incidence of cerebrovascular accidents after ECT in these patients. METHOD: A systematic literature search was performed according to the PRISMA guidelines in PubMed and in the Cochrane Library. Publications in which ECT was applied in patients with a history of stroke were included by using specific MeSH terms. RESULTS: The following 19 articles met the criteria for review: 1 wide-scale prospective study, 1 small-scale prospective study with a control group, 3 small-scale retrospective studies, and 14 case reports. In the vast longitudinal Danish study, ECT was not associated with an elevated risk of recurrent stroke. Similarly, none of the other studies found the risk to be raised. CONCLUSION: Despite the limited number of prospective studies and the methodological discrepancies in the reports, ECT does not seem to be associated with an elevated risk of recurrent stroke. This review supports the safe use of ECT in patients with a recent or past history of stroke, if prior neurologic and cardiovascular assessments are being performed, as well as monitoring during the treatment.

Key design elements of successful acute ischemic stroke treatment trials.

PURPOSE: We review key design elements of positive randomized controlled trials (RCTs) in acute ischemic stroke (AIS) treatment and summarize their main characteristics. METHOD: We searched Medline, Pubmed and Cochrane databases for positive RCTs in AIS treatment. Trials were included if (1) they had a randomized controlled design, with (at least partial) blinding for endpoints, (2) they tested against placebo (or on top of standard therapy in a superiority design) or against approved therapy; (3) the protocol was registered and/or published before trial termination and unblinding (if required at study commencement); (4) the primary endpoint was positive in the intention to treat analysis; and (5) the study findings led to approval of the investigational product and/or high ranked recommendations. A topical approach was used, therefore the findings were summarized as a narrative review. FINDINGS: Seventeen positive RCTs met the inclusion criteria. The majority of trials included less than 1000 patients (n = 15), had highly selective inclusion criteria (n = 16), used the modified Rankin score as a primary endpoint (n = 15) and had a frequentist design (n = 16). Trials tended to be national (n = 12), investigator-initiated and performed with public funding (n = 11). DISCUSSION: Smaller but selective trials are useful to identify efficacy in a particular subgroup of stroke patients. It may also be of advantage to limit the number of participating countries and centers to avoid heterogeneity in stroke management and bureaucratic burden. CONCLUSION: The key characteristics of positive RCTs in AIS treatment described here may assist in the design of further trials investigating a single intervention with a potentially high effect size.

Quality of life in patients and caregivers after aneurysmal subarachnoid hemorrhage: a Flemish population study.

BACKGROUND AND AIMS: Aneurysmal subarachnoid hemorrhages (aSAH) have high mortality and morbidity. However, the impact on Quality of Life (QoL) of patients remains poorly documented, and data on primary caregiver burden is even scarcer. METHODS: This is a single center, cross-sectional study performed at the Antwerp University Hospital, Belgium. We included aSAH patients during follow-up at the outpatient clinic and assessed the QoL, by using the Stroke Specific Quality of Life scale (SSQoL). Caregiver burden was evaluated by the Caregiver Strain Index (CSI). The aSAH severity and functional outcome (at 90 days) were assessed, respectively, by mFisher score and modified Ranking Scale (mRS). Statistical analysis was performed using SPSS version 27. RESULTS: In total, 22 aSAH patients were included, on average 15.5 (range 4-45) months after the aSAH. The SSQoL score was 3.7 ± 0.7, with a mean psychosocial domain score of 3.2 ± 0.8 and physical domain of 4.2 ± 0.8. Psychosocial factors, especially decreased energy levels and cognitive impairment, had a negative impact on the QoL (p = 0.02 en p = 0.05). No association was found between QoL and mFisher, nor between QoL and mRS. Fifteen primary caregivers completed the CSI. Only 3 (20%) of them reported a high care burden (CSI > 6), although changes in daily life and personal plans were reported, respectively, by 73% (n = 11) and 67% (n = 10) of caregivers. We only found a correlation between the mFisher score and CSI (p = 0.01). CONCLUSION: Our results emphasize that there is an important psychosocial impact on the QoL of patients after aSAH, and their primary caregivers. More research is warranted.

Characteristics of patients with atrial fibrillation prescribed edoxaban in Belgium and the Netherlands: insights from the ETNA-AF-Europe study.

BACKGROUND: Studies on the use of non-vitamin K antagonist oral anticoagulants in unselected patients with atrial fibrillation (AF) show that clinical characteristics and dosing practices differ per region, but lack data on edoxaban. METHODS: With data from Edoxaban Treatment in routiNe clinical prActice for patients with AF in Europe (ETNA-AF-Europe), a large prospective observational study, we compared clinical characteristics (including the dose reduction criteria for edoxaban: creatinine clearance 15-50 ml/min, weight ≤60 kg, and/or use of strong p­glycoprotein inhibitors) of patients from Belgium and the Netherlands (BeNe) with those from other European countries (OEC). RESULTS: Of all 13,639 patients in ETNA-AF-Europe, 2579 were from BeNe. BeNe patients were younger than OEC patients (mean age: 72.3 vs 73.9 years), and had lower CHA2DS2-VASc (mean: 2.8 vs 3.2) and HAS-BLED scores (mean: 2.4 vs 2.6). Patients from BeNe less often had hypertension (61.6% vs 80.4%), and/or diabetes mellitus (17.3% vs 23.1%) than patients from OEC. Moreover, relatively fewer patients in BeNe were prescribed the reduced dose of 30 mg edoxaban (14.8%) than in OEC (25.4%). Overall, edoxaban was dosed according to label in 83.1% of patients. Yet, 30 mg edoxaban was prescribed in the absence of any dose reduction criteria in 36.9% of 30 mg users (5.5% of all patients) in BeNe compared with 35.5% (9.0% of all patients) in OEC. CONCLUSION: There were several notable differences between BeNe and OEC regarding clinical characteristics and dosing practices in patients prescribed edoxaban, which are relevant for the local implementation of dose evaluation and optimisation. TRIAL REGISTRATION: NCT02944019; Date of registration 24 October 2016.

HIV sero-positivity and risk factors for ischaemic and haemorrhagic stroke in hospitalised patients in Uganda: A prospective-case-control study.

Objectives: We examined HIV sero-positivity and risk factors in patients admitted with ischaemic stroke (IS) and haemorrhagic stroke (HS) in Kampala, Uganda. Study design: We conducted a matched case-control study between December 2016 and December 2018 â€‹at â€‹St Francis Hospital, Nsambya. Methods: The study population comprised of stroke cases (adults aged ≥18 years with IS or HS confirmed by neuroimaging) and controls (age- and sex-matched stroke-free adults aged ≥18 years who were recruited from the same hospital as the cases). A comprehensive assessment for sociodemographic, lifestyle and clinical factors was performed using the World Health Organization (WHO) STEP-wise approach to Surveillance (STEPS) for stroke risk factor surveillance. We used conditional logistic regression to identify risk factors associated with IS or HS. Results: We enrolled 137 matched case-control pairs; 48 (35%) were men, and the mean ages were 62.4 years (SD â€‹± â€‹14.8) for cases and 61.1 years (SD â€‹± â€‹14.1) for controls. Of stroke patients, 86 (63%) had IS and 51 (37%) had HS. Overall, HIV sero-positivity was 10% among stroke cases versus 7% among controls. HIV sero-positivity was not significantly associated with stroke (unadjusted odds ratio [uOR] â€‹= â€‹1.49, 95% confidence interval [CI] 0.59-3.78). A self-reported family history of diabetes mellitus was associated with an increased risk of all stroke (adjusted odds ratio [aOR] â€‹= â€‹4.41, 95% CI 1.47-13.2), as well as for IS and HS separately (aOR â€‹= â€‹3.66, 95% CI 1.09-12.4 and aOR â€‹= â€‹4.99, 95% CI 1.02-24.4, respectively). High blood pressure (≥140/90 â€‹mmHg) was associated with an increased risk of all stroke (aOR â€‹= â€‹12.3, 95% CI 42-44.1), and this was also true for IS and HS individually (aOR â€‹= â€‹6.48, 95% CI 1.15-36.7 and aOR â€‹= â€‹5.63, 95% CI 1.74-18.2, respectively). Conclusions: No association was found between HIV sero-positivity and stroke occurrence among Ugandan stroke patients. Hypertension and a self-reported family history of diabetes mellitus were significant risk factors for both IS and HS. Interventions to reduce hypertension and diabetes mellitus in the Ugandan population are urgently required. Much larger studies are required to demonstrate if any association exists between HIV and stroke.

Stroke coach: a pilot study of a personal digital coaching program for patients after ischemic stroke.

Despite recent advances in acute stroke care, the risk of recurrent stroke remains high. On behalf of the Belgian Stroke Council (BSC), a nurse-led self-management program was developed, using a personal coach and digital platform with the aim of improving cardiovascular risk factor control in patients after ischemic stroke. The program was implemented in four Belgian hospitals. The stroke coach provided one educational session during hospitalization. After discharge, the patient received tips and tricks concerning a healthy lifestyle through the customized platform. The stroke coach set up video appointments through the platform at regular intervals. Primary endpoint of our study was the change in SCORE (Systematic COronary Risk Evaluation: High and Low cardiovascular Risk Charts) risk at baseline and 6 months compared with a historical control group who received standard care. A total of 147 patients were included for a follow-up period of 6 months. The mean SCORE in the intervention group showed a statistically significant reduction of 3.2 (p < 0.001) at 6 months. However, comparison between control and intervention groups was non-significant (p = 0.55). Secondary endpoints are promising with a medication adherence of 96%. Reported quality of life also improved (p < 0.001). No significant improvement in the modified Rankin scale (mRS) was observed (p = 0.720). Five percent of patients suffered a recurrent stroke. Our project consisting of a coached lifestyle intervention and digital platform shows promise in improving stroke recurrence rates, therapeutic adherence and quality of life in a Belgian healthcare setting.

An individualized coaching program for patients with acute ischemic stroke: Feasibility study.

OBJECTIVES: An individualized stroke care program was developed to match patients' education with their needs regarding stroke knowledge, secondary prevention and rehabilitation. Our purpose was to assess feasibility of in-hospital and post-discharge, personalized stroke coaching service. METHODS: Acute ischemic stroke patients enrolled in ASTRAL-B stroke registry (Sint-Lucashospital, Bruges Belgium) with: (a) hospitalization between 12/2014-12/2015, (b) hospital-to-home discharge, and (c) without cognitive decline, were selected. The stroke coach contacted patients individually twice during hospitalization (2×20min) and post-discharge via phone calls using the standardized WSO Post-Strokechecklist. Risk factor management, review of therapy and clinical evolution were discussed. Participants were contacted at 2 weeks, followed by repeat calls if necessary and ambulatory with the vascular neurologist at 1, 3, 6 and 12 months. RESULTS: Of all 255 patients meeting the inclusion criteria, 152 (59.7%) received individualized education during hospitalization by the stroke coach. Median age of our population was 74 years and median NIHSS 5. Majority of patients had at least two cardiovascular risk factors. Patients were not coached because of palliative care/decease (10%), unfavorable life expectancy (2%), dementia (8.5%) and lack of time due to short hospitalization (22%). A quarter of all patients were contacted at least once by phone, 12% were contacted at least twice after discharge. At three months, low stroke recurrence (5%) and mortality rates (4%) were identified, probably linked to improved adherence. CONCLUSIONS: We demonstrated feasibility of an individualized coaching service executed by well-trained stroke nurse. Future research will focus on developing an online portal delivering post-discharge services to patients and caregivers.