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BACKGROUND AND PURPOSE: The increased severity of white matter disease is associated with worse outcomes and an increased rate of intracerebral hemorrhage in patients with ischemic stroke undergoing thrombolytic treatment. However, whether white matter disease is associated with outcomes in patients undergoing endovascular treatment remains unclear. MATERIALS AND METHODS: In this prespecified exploratory analysis of our prospective multi-institutional study that enrolled consecutive adult patients with anterior circulation ischemic stroke undergoing endovascular treatment from November 2017 to September 2018, we compared the following outcomes between patients with none-to-minimal (van Swieten score, 0-2) and moderate-to-severe (van Swieten score, 3-4) white matter disease using logistic regression: 90-day mRS 3-6, death, intracerebral hemorrhage, successful recanalization, and early neurologic recovery. RESULTS: Of the 485 patients enrolled in the Blood Pressure after Endovascular Stroke Therapy (BEST) study, 389 had white matter disease graded (50% women; median age, 68 years; range, 58-79 years). A van Swieten score of 3-4 (n = 74/389, 19%) was associated with a higher rate of 90-day mRS of 3-6 (45% versus 18%; adjusted OR, 2.73; 95% CI, 1.34-5.93; P = .008). Although the death rate was higher in patients with van Swieten scores of 3-4 (26% versus 15%), the adjusted likelihood was not significantly different (adjusted OR, 1.14; 95% CI, 0.56-2.26; P = .710). Ordered regression revealed a shift toward worse mRS scores with increasing van Swieten scores (adjusted common OR, 3.04; 95% CI, 1.93-4.84; P < .001). No associations between white matter disease severity and intracerebral hemorrhage, successful recanalization, and early neurologic recovery were observed. CONCLUSIONS: Moderate-to-severe white matter disease is associated with worse outcomes in patients undergoing endovascular treatment without a significant increase in hemorrhagic complications. Studies comparing patients with and without endovascular treatment are necessary to determine whether the benefit of endovascular treatment is attenuated with greater white matter disease.
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Leucoencefalopatías/complicaciones , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/cirugía , Trombectomía/métodos , Resultado del Tratamiento , Anciano , Isquemia Encefálica/complicaciones , Procedimientos Endovasculares/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
BACKGROUND AND PURPOSE: Cancer is a frequent finding in ischaemic stroke patients. The frequency of cancer amongst participants in the NAVIGATE ESUS randomized trial and the distribution of outcome events during treatment with aspirin and rivaroxaban were investigated. METHODS: Trial participation required a recent embolic stroke of undetermined source. Patients' history of cancer was recorded at the time of study entry. During a mean follow-up of 11 months, the effects of aspirin and rivaroxaban treatment on recurrent ischaemic stroke, major bleeding and all-cause mortality were compared between patients with cancer and patients without cancer. RESULTS: Amongst 7213 randomized patients, 543 (7.5%) had cancer. Of all patients, 3609 were randomized to rivaroxaban [254 (7.0%) with cancer] and 3604 patients to aspirin [289 (8.0%) with cancer]. The annual rate of recurrent ischaemic stroke was 4.5% in non-cancer patients in the rivaroxaban arm and 4.6% in the aspirin arm [hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.78-1.24]. In cancer patients, the rate of recurrent ischaemic stroke was 7.7% in the rivaroxaban arm and 5.4% in the aspirin arm (HR 1.43, 95% CI 0.71-2.87). Amongst cancer patients, the annual rate of major bleeds was non-significantly higher for rivaroxaban than aspirin (2.9% vs. 1.1%; HR 2.57, 95% CI 0.67-9.96; P for interaction 0.95). All-cause mortality was similar in both groups. CONCLUSIONS: Our exploratory analyses show that patients with embolic stroke of undetermined source and a history of cancer had similar rates of recurrent ischaemic strokes and all-cause mortality during aspirin and rivaroxaban treatments and that aspirin appeared safer than rivaroxaban in cancer patients regarding major bleeds. www.clinicaltrials.gov (NCT02313909).
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Isquemia Encefálica , Embolia Intracraneal , Accidente Cerebrovascular Isquémico , Aspirina/uso terapéutico , Isquemia Encefálica/complicaciones , Isquemia Encefálica/tratamiento farmacológico , Isquemia Encefálica/prevención & control , Método Doble Ciego , Inhibidores del Factor Xa , Humanos , Neoplasias/complicaciones , Inhibidores de Agregación Plaquetaria/efectos adversos , Rivaroxabán/uso terapéutico , Prevención SecundariaRESUMEN
BACKGROUND: Over the last quarter-century, the number of publications using vessel wall MR imaging has increased. Although many narrative reviews offer insight into technique and diagnostic applications, a systematic review of publication trends and reporting quality has not been conducted to identify unmet needs and future directions. PURPOSE: We aimed to identify which intracranial vasculopathies need more data and to highlight areas of strengths and weaknesses in reporting. DATA SOURCES: PubMed, EMBASE, and MEDLINE databases were searched up to September 2018 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA ANALYSIS: Two independent reviewers screened and extracted data from 128 articles. The Strengthening the Reporting of Observational Studies in Epidemiology guidelines were used to assess the reporting quality of analytic observational studies. DATA SYNTHESIS: There has been an exponentially increasing trend in the number of vessel wall MR imaging publications during the past 24 years (P < .0001). Intracranial atherosclerosis is the most commonly studied intracranial vasculopathy (49%), followed by dissections (13%), aneurysms (8%), and vasculitis (5%). Analytic observational study designs composed 48% of the studies. Transcontinental collaborations showed nonsignificantly higher reporting quality compared with work originating from single continents (P = .20). LIMITATIONS: A limitation is the heterogeneity in study designs. CONCLUSIONS: Investigations on the diagnostic utility of vessel wall MR imaging in less commonly studied intracranial vasculopathies such as dissections, aneurysms, and vasculitis are warranted. More consistent adherence to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines should improve transparency and maximize effective synthesis for clinical translation. Diverse collaborative teams are encouraged to advance the understanding of intracranial vasculopathies using vessel wall MR imaging.
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Vasos Sanguíneos/diagnóstico por imagen , Encéfalo/diagnóstico por imagen , Trastornos Cerebrovasculares/diagnóstico por imagen , Imagen por Resonancia Magnética/normas , Métodos Epidemiológicos , Guías como Asunto , Humanos , Imagen por Resonancia Magnética/métodos , Estudios Observacionales como AsuntoRESUMEN
INTRODUCTION: The red cell distribution width (RDW) is a biomarker strongly associated with poor outcome in inflammatory and thrombotic diseases. Subarachnoid hemorrhage (SAH) is both an inflammatory and thrombotic state in which many biomarkers have been studied. In this exploratory pilot study, we sought to determine whether RDW predicts poor outcome in patients with SAH. METHODS: Patients with moderate-to-severe SAH were prospectively enrolled in an observational study of biomarkers and outcome. CBC, ESR, high sensitivity CRP, D-dimer, and fibrinogen were obtained on post-bleed days (PBD) 1, 3, 5, 7, and 10. Poor outcome was defined as a modified Rankin score of 3-6 at 90-days. RESULTS: Of 40 patients, 5 (12.5%) died and 19 (47.5%) had a poor outcome. RDW (p = 0.046) when measured serially over the study period, was significantly higher among patients with poor outcome. Maximum RDW (OR 2.3 95% CI 1.2-3.6; p = 0.014) and maximum WBC count (OR 1.29 95% CI 1.04-1.60; p = 0.018) were associated with poor outcome. Stepwise addition of maximum ESR, CRP, D-dimer, and fibrinogen yielded a model with RDW (OR 2.54 95% CI 1.21-5.35; p = 0.014) and fibrinogen (OR 1.01 95% CI 1.002-1.01; p = 0.004) predicting outcome. With addition of age and Hunt and Hess grade, RDW, fibrinogen, and high-grade status remained significantly associated with poor outcome. Use of PBD1 RDW in lieu of maximum RDW, resulted in a similar model. CONCLUSIONS: An elevated RDW is associated with poor outcome in SAH patients. RDW may be a useful predictor of outcomes after SAH.
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Tamaño de la Célula , Eritrocitos/citología , Evaluación de Resultado en la Atención de Salud , Hemorragia Subaracnoidea/sangre , Anciano , Biomarcadores/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Hemorragia Subaracnoidea/mortalidad , Hemorragia Subaracnoidea/terapiaRESUMEN
RATIONALE: Transcranial laser therapy is undergoing clinical trials in patients with acute ischemic stroke. The NeuroThera® Efficacy and Safety Trial-1 was strongly positive for 90-day functional benefit with transcranial laser therapy, and post hoc analyses of the subsequent NeuroThera® Efficacy and Safety Trial-2 trial suggested a meaningful beneficial effect in patients with moderate to moderately severe ischemic stroke within 24 h of onset. These served as the basis for the NeuroThera® Efficacy and Safety Trial-3 randomized controlled trial. AIM: The purpose of this pivotal study was to demonstrate safety and efficacy of transcranial laser therapy with the NeuroThera® Laser System in the treatment of subjects diagnosed with acute ischemic stroke. DESIGN: NeuroThera® Efficacy and Safety Trial-3 is a double-blind, randomized, sham-controlled, parallel group, multicenter, pivotal study that will enroll 1000 subjects at up to 50 sites. All subjects will receive standard medical management based on the American Stroke Association and European Stroke Organization Guidelines. In addition to standard medical management, both groups will undergo the transcranial laser therapy procedure between 4·5 and 24 h of stroke onset. The study population will be randomized into two arms: the sham control group will receive a sham transcranial laser therapy procedure and the transcranial laser therapy group will receive an active transcranial laser therapy procedure. The randomization ratio will be 1:1 and will be stratified to ensure a balanced subject distribution between study arms. STUDY OUTCOMES: The primary efficacy end point is disability at 90 days (or the last rating), as assessed on the modified Rankin Scale, dichotomized as a success (a score of 0-2) or a failure (a score of 3 to 6).
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Isquemia Encefálica/terapia , Terapia por Láser/métodos , Accidente Cerebrovascular/terapia , Adulto , Anciano , Anciano de 80 o más Años , Método Doble Ciego , Estudios de Seguimiento , Humanos , Terapia por Láser/efectos adversos , Terapia por Láser/instrumentación , Persona de Mediana Edad , Selección de Paciente , Tiempo de Tratamiento , Resultado del TratamientoRESUMEN
We prospectively compared the accuracies of conventional transcranial Doppler ultrasound (TCD) and transcranial color-coded duplex sonography (TCCS) in the diagnosis of narrowing of the basilar (BA) and vertebral arteries (VA). Fifty-six consecutive patients (mean age 55.8 years; 34 women) after subarachnoid hemorrhage (n=46), stroke or transient ischemic attack (n=5), and for other reasons (n=5) underwent on the same day TCD, TCCS and the intra-arterial digital subtraction angiography (DSA) - the reference standard. The accuracy of peak-systolic (VPS), mean (VM), and end-diastolic velocities (VED) in detection of any arterial narrowing was estimated using the receiver operator characteristic (ROC) curve methodology and the total area (Az) under the curve. Accuracy of TCCS in detection of VA narrowing based on VPS and VM measurements was significantly higher than accuracy of TCD (Az=0.65 for VPS and Az=0.62 for VM versus Az=0.51 and Az=0.50, respectively, p<0.05 for both). Accuracy of TCCS in detection of BA narrowing was also higher than accuracy of TCD based on VPS measurements (Az=0.69 versus Az=0.50, respectively), with a trend toward significant difference, p=0.085. The accuracy of TCCS is superior to accuracy of TCD in detection of narrowings of vertebral and basilar arteries, thus TCCS should be preferred in routine clinical practice.
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OBJECTIVE: To investigate whether cervical carotid artery dissection (CCAD) is associated with anatomic characteristics of the styloid process of the temporal bone. METHODS: CT angiograms from 38 case patients with CCAD and 38 age- and sex-matched control subjects without dissection were studied. Styloid process length, angulation in the axial and rostral-caudal planes, and proximity to the carotid artery were measured bilaterally by raters blinded to radiology reports and clinical information. RESULTS: In control subjects, there was substantial variation in styloid process length (range 4.6-42.9 mm), medial angulation (range 16-89°), caudal angulation (range 31-80°), and proximity to the carotid (range 0.7-15.4 mm). Control subjects also demonstrated marked symmetry between sides (correlation coefficients 0.80 for length, 0.34 for proximity, 0.81 for medial angulation, and 0.87 for caudal angulation). In case patients, the mean styloid length on the side of the dissection was not significantly longer than that on the contralateral side (mean 30.3 vs 29.7 mm, p = 0.30). The styloid process was significantly longer ipsilateral to the dissection in case patients compared with the side-matched process in control subjects (mean 30.3 vs 26.6 mm, p = 0.03). Carotid dissection was associated with increasing styloid process length (OR [OR] 1.08/mm, 95% confidence interval [CI] 1.002-1.17, p = 0.04). The OR of dissection in the highest quartile of length compared with that in the lower 3 quartiles was 4.0 (95% CI 1.3-14.2, p = 0.03). CONCLUSIONS: CCAD is associated with a longer styloid process, suggesting that mechanical injury from the styloid may contribute to the pathogenesis of CCAD.
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Disección de la Arteria Carótida Interna/etiología , Arteria Carótida Interna/patología , Hueso Temporal/anatomía & histología , Tomografía Computarizada por Rayos X , Adulto , Anciano , Angiografía , Arteria Carótida Interna/diagnóstico por imagen , Disección de la Arteria Carótida Interna/diagnóstico por imagen , Disección de la Arteria Carótida Interna/patología , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Hueso Temporal/diagnóstico por imagen , Adulto JovenRESUMEN
BACKGROUND: Use of antihypertensive medications is common after intracerebral hemorrhage (ICH). Medications that block adrenergic activation (e.g., beta-blockers and the alpha(2)-agonist, clonidine) may reduce the inflammatory response and therefore have secondary benefit after ICH. METHODS: The patients with acute ICH enrolled in the placebo arm of the CHANT trial were included. Univariate and multivariate analyses were undertaken for factors associated with blood pressure medication use, edema at 72 h, and clinical outcome at 90 days. RESULTS: Of the 303 patients, 87.8% received some antihypertensive treatment during the first 72 h of hospitalization. Edema volume on neuroimaging at 72 h was independently associated with clinical outcome. Use of anti-adrenergic medications was associated with less edema after controlling for hemorrhage volume and blood pressure. CONCLUSIONS: Antihypertensive medications that antagonize the sympathetic nervous system may reduce perihematomal edema after ICH.
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Agonistas de Receptores Adrenérgicos alfa 2/uso terapéutico , Antagonistas Adrenérgicos beta/uso terapéutico , Antihipertensivos/uso terapéutico , Antioxidantes/uso terapéutico , Bencenosulfonatos/uso terapéutico , Edema Encefálico/prevención & control , Hemorragia Cerebral/tratamiento farmacológico , Clonidina/uso terapéutico , Cuidados Críticos/métodos , Depuradores de Radicales Libres/uso terapéutico , Anciano , Presión Sanguínea/efectos de los fármacos , Estudios de Cohortes , Método Doble Ciego , Quimioterapia Combinada , Femenino , Escala de Coma de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Prospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Despite the high incidence of acute stroke, only a minority of patients are enrolled in acute stroke treatment trials. We aimed to identify factors associated with participation in clinical trials of novel therapeutic agents for acute stroke. METHODS: Prospective survey of patients with acute stroke <72 hours from onset. A structured interview was administered to the patient or primary decision-maker. If offered participation in an actual acute treatment trial, questions focused on decisions about that trial; otherwise a similar mock trial was proposed. The primary outcome was whether the subject agreed to participate in the proposed trial. RESULTS: A total of 200 subjects (47% patients, 53% proxies) completed the survey: mean age 63 +/- 14 years, 47% women, 44% white, 50% black. A real acute trial was offered to 22%; others were offered a mock trial. Overall, 57% (95% confidence interval: 50%-64%) of respondents stated they would participate in the proposed acute treatment trial. There were no differences with respect to age, sex, race, educational level, self-assessed stroke severity or stroke type, vascular risk factors, or comorbidities. Misconceptions about key research concepts were found in 50% but did not impact participation. Participation was associated with the perceived risk of the proposed trial intervention (p < 0.001), prior general attitudes about research (p < 0.001), and influences attributed to family, religion, and other personal beliefs (p < 0.001). Patients were more likely to participate than proxy decision-makers (p = 0.04). CONCLUSIONS: Demographic factors, clinical factors, and prior knowledge about research have little impact on the decision to participate in acute stroke clinical trials. Preexisting negative attitudes and external influences about research strongly inhibit participation. Patients are more inclined to participate than their proxy decision-makers.
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Ensayos Clínicos como Asunto/psicología , Recolección de Datos/métodos , Consentimiento Informado/psicología , Competencia Mental/psicología , Cooperación del Paciente/psicología , Accidente Cerebrovascular/tratamiento farmacológico , Enfermedad Aguda/terapia , Anciano , Actitud Frente a la Salud , Investigación Biomédica/ética , Cuidadores/psicología , Cuidadores/estadística & datos numéricos , Ensayos Clínicos como Asunto/estadística & datos numéricos , Cultura , Femenino , Humanos , Consentimiento Informado/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Cooperación del Paciente/estadística & datos numéricos , Educación del Paciente como Asunto/estadística & datos numéricos , Relaciones Médico-Paciente , Estudios Prospectivos , Medición de Riesgo/estadística & datos numéricos , Asunción de RiesgosRESUMEN
BACKGROUND: There are limited data on the relationship between patient and site characteristics and clinical outcomes after intracranial stenting. METHODS: We performed a multivariable analysis that correlated patient and site characteristics with the occurrence of the primary endpoint (any stroke or death within 30 days of stenting or stroke in the territory of the stented artery beyond 30 days) in 160 patients enrolled in this stenting registry. All patients presented with an ischemic stroke, TIA, or other cerebral ischemic event (e.g., vertebrobasilar insufficiency) in the territory of a suspected 50-99% stenosis of a major intracranial artery while on antithrombotic therapy. RESULTS: Cerebral angiography confirmed that 99% (158/160) of patients had a 50-99% stenosis. In multivariable analysis, the primary endpoint was associated with posterior circulation stenosis (vs anterior circulation) (hazard ratio [HR] 3.4, 95% confidence interval [CI] 1.2-9.3, p = 0.018), stenting at low enrollment sites (< 10 patients each) (vs high enrollment site) (HR 2.8, 95% CI 1.1-7.6, p = 0.038), < or = 10 days from qualifying event to stenting (vs > or = 10 days) (HR 2.7, 95% CI 1.0-7.8, p = 0.058), and stroke as a qualifying event (vs TIA/other) (HR 3.2, 95% CI 0.9-11.2, p = 0.064). There was no significant difference in the primary endpoint based on age, gender, race, or percent stenosis (50-69% vs 70-99%). CONCLUSIONS: Major cerebrovascular complications after intracranial stenting may be associated with posterior circulation stenosis, low volume sites, stenting soon after a qualifying event, and stroke as the qualifying event. These factors will need to be monitored in future trials of intracranial stenting.
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Trombosis Intracraneal/terapia , Complicaciones Posoperatorias/mortalidad , Stents/efectos adversos , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidad , Centros Médicos Académicos/estadística & datos numéricos , Anciano , Infarto Encefálico/etiología , Infarto Encefálico/mortalidad , Determinación de Punto Final , Femenino , Humanos , Masculino , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/administración & dosificación , Competencia Profesional/estadística & datos numéricos , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Stents/estadística & datos numéricos , Insuficiencia Vertebrobasilar/terapiaRESUMEN
OBJECTIVE: To examine whether antiplatelet medication use at onset of intracerebral hemorrhage (ICH) is associated with hemorrhage growth and outcome after spontaneous ICH using a large, prospectively collected database from a recent clinical trial. METHODS: The Cerebral Hemorrhage and NXY-059 Treatment trial was a randomized, placebo-controlled trial of NXY-059 after spontaneous ICH. We analyzed patients in the placebo arm, and correlated antiplatelet medication use at the time of ICH with initial ICH volumes, ICH growth in the first 72 hours, and modified Rankin Score at 90 days. Patients on oral anticoagulation were excluded. RESULTS: There were 282 patients included in this analysis, including 70 (24.8%) who were taking antiplatelet medications at ICH onset. Use of antiplatelet medications at ICH onset had no association with the volume of ICH at presentation, growth of ICH at 72 hours, initial edema volume, or edema growth. In multivariable analysis, there was no association of use of antiplatelet medications with any hemorrhage expansion (relative risk [RR] 0.85 [upper limit of confidence interval (UCI) 1.03], p = 0.16), hemorrhage expansion greater than 33% (RR 0.77 [UCI 1.18], p = 0.32), or clinical outcome at 90 days (odds ratio 0.67, 95% confidence interval 0.39-1.14, p = 0.14). CONCLUSIONS: Use of antiplatelet medications at intracerebral hemorrhage (ICH) onset is not associated with increased hemorrhage volumes, hemorrhage expansion, or clinical outcome at 90 days. These findings suggest that attempts to reverse antiplatelet medications after ICH may not be warranted.
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Encéfalo/efectos de los fármacos , Encéfalo/patología , Hemorragia Cerebral/inducido químicamente , Hemorragia Cerebral/patología , Inhibidores de Agregación Plaquetaria/efectos adversos , Anciano , Encéfalo/irrigación sanguínea , Edema Encefálico/inducido químicamente , Edema Encefálico/patología , Edema Encefálico/fisiopatología , Causalidad , Hemorragia Cerebral/fisiopatología , Progresión de la Enfermedad , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos , Femenino , Humanos , Enfermedad Iatrogénica/prevención & control , Procesamiento de Imagen Asistido por Computador , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud/métodos , Estudios Prospectivos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Blood pressure (BP) is the major determinant of cerebral perfusion yet blood pressure management in acute stroke is complex and controversial. Optimized blood pressure management may improve outcomes in patients with ischemic and hemorrhagic stroke although the available data are conflicting and target BP goals are not well defined. We review the current literature, published guidelines, and emerging research on this important topic. Additionally, the treatment algorithm which we employ is discussed.
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Presión Sanguínea , Infarto Encefálico/fisiopatología , Hemorragia Cerebral/fisiopatología , Circulación Cerebrovascular , Hipertensión/tratamiento farmacológico , Algoritmos , Infarto Encefálico/complicaciones , Hemorragia Cerebral/complicaciones , Humanos , Hipertensión/etiología , Guías de Práctica Clínica como AsuntoRESUMEN
BACKGROUND: There are limited data on the relationship between control of vascular risk factors and vascular events in patients with symptomatic intracranial arterial stenosis. METHODS: We utilized the Warfarin Aspirin Symptomatic Intracranial Disease study database to analyze vascular and lifestyle risk factors at baseline and averaged over the course of the trial. Cutoff levels defining good control for each factor were prespecified based on national guidelines. Endpoints evaluated included 1) ischemic stroke, myocardial infarction, or vascular death or 2) ischemic stroke alone. Univariate associations were assessed using the log-rank test and multivariable analysis was done using Cox proportional hazards regression. RESULTS: From baseline until year 2 follow-up, there was not a significant improvement in blood pressure control. During the same period, there were improvements in patients with total cholesterol <200 mg/dL (54.6% to 79.2%, p < 0.001) or low-density lipoprotein <100 mg/dL (28.7% to 55.9%, p < 0.001). Multivariable analysis showed that systolic blood pressure >or=140 mm Hg (HR = 1.79, p = 0.0009, 95% confidence limits 1.27 to 2.52), no alcohol consumption (HR 1.69, 1.21 to 2.39, p = 0.002), and cholesterol >or=200 mg/dL (HR 1.44, 1.004 to 2.07, p = 0.048) were associated with an increased risk of stroke, myocardial infarction, or vascular death. The same risk factors were predictors of ischemic stroke alone in multivariable analysis. CONCLUSIONS: Elevated blood pressure and cholesterol levels in symptomatic patients with intracranial stenosis are associated with an increased risk of stroke and other major vascular events.
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Arteriosclerosis Intracraneal/complicaciones , Arteriosclerosis Intracraneal/epidemiología , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Anciano , Constricción Patológica/complicaciones , Constricción Patológica/epidemiología , Constricción Patológica/patología , Femenino , Estudios de Seguimiento , Humanos , Arteriosclerosis Intracraneal/patología , Masculino , Persona de Mediana Edad , Estudios Multicéntricos como Asunto/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Factores de Riesgo , Accidente Cerebrovascular/patología , Warfarina/uso terapéuticoRESUMEN
The WASID trial showed no advantage of warfarin over aspirin for preventing the primary endpoint of ischemic stroke, brain hemorrhage, or vascular death. In analyses of selected subgroups, there was no definite benefit from warfarin. Warfarin reduced the risk of the primary endpoint among patients with basilar artery stenosis, but there was no reduction in stroke in the basilar artery territory or benefit for vertebral artery stenosis or posterior circulation disease in general.
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Aspirina/uso terapéutico , Enfermedades Arteriales Cerebrales/tratamiento farmacológico , Enfermedades Arteriales Cerebrales/mortalidad , Medición de Riesgo/métodos , Warfarina/uso terapéutico , Anciano , Anciano de 80 o más Años , Antiinflamatorios no Esteroideos/uso terapéutico , Anticoagulantes/uso terapéutico , Enfermedades Arteriales Cerebrales/diagnóstico , Constricción Patológica/diagnóstico , Constricción Patológica/tratamiento farmacológico , Constricción Patológica/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Análisis de Supervivencia , Tasa de Supervivencia , Resultado del Tratamiento , Estados Unidos/epidemiologíaAsunto(s)
Inmunosupresores/efectos adversos , Trasplante de Riñón/efectos adversos , Trasplante de Hígado/efectos adversos , Sirolimus/efectos adversos , Trasplante , Encéfalo/efectos de los fármacos , Encéfalo/patología , Encéfalo/fisiopatología , Estudios de Cohortes , Demencia Vascular/inducido químicamente , Demencia Vascular/patología , Demencia Vascular/fisiopatología , Humanos , Trasplante de Pulmón , Estudios Retrospectivos , Estado Epiléptico/inducido químicamente , Estado Epiléptico/patología , Estado Epiléptico/fisiopatologíaRESUMEN
Many studies have found that women have a higher risk of perioperative stroke or death from carotid endarterectomy. Other vascular surgical procedures have demonstrated that body size and morphology impact on operative risk. We correlated the 30 day operative risk of stroke and death in the European Carotid Surgery Trial (ECST) with height, weight, body surface area (BSA), and body mass index using single variable analyses and multivariable logistic regression. Women were at significantly higher risk of perioperative stroke and death in the ECST. Both height and BSA confounded the effect of sex, implying that the generally smaller size of women may contribute to their increased risk. This finding should be validated in other large datasets.
Asunto(s)
Estatura , Superficie Corporal , Endarterectomía Carotidea/efectos adversos , Complicaciones Posoperatorias , Accidente Cerebrovascular/etiología , Anciano , Endarterectomía Carotidea/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Factores SexualesRESUMEN
OBJECTIVES: 1) To evaluate the risk of subsequent stroke or death in patients with a cryptogenic stroke and a patent foramen ovale (PFO), atrial septal aneurysm (ASA), or both. 2) To establish the optimal method of stroke prevention in this population of patients. METHODS: MEDLINE, the Cochrane database of systematic reviews, key meeting abstracts from 1997 to 2002, and relevant reference lists were searched to select studies that prospectively collected outcome data in cryptogenic stroke patients with and without interatrial septal abnormalities. Studies were also selected that prospectively compared at least two treatment options. The quality of each study was graded (class I to IV) using a standard classification-of-evidence scheme for each question. Risk analyses were performed and data were pooled when appropriate. RESULTS: The literature search generated 129 articles of which only four fulfilled the inclusion and exclusion criteria. Two studies were graded class I, one study was graded class II, and one study was graded class IV for prognosis. Pooled results of the two class I and one class II studies demonstrated no increased risk of subsequent stroke or death in patients with PFO compared to those without (RR = 0.95, 95% CI 0.62 to 1.44). One class I study found increased risk of recurrent stroke in patients with PFO and ASA (annual rate = 3.8% versus 1.05%, RR = 2.98, 95% CI 1.17 to 7.58) but not increased risk of a composite of stroke and death (annual rate = 3.8% versus 1.8%, RR = 2.10, 95% CI 0.86 to 5.06). Regarding therapy, one study was graded class II, one study class III, and two studies class IV. Among patients with cryptogenic stroke and PFO or ASA, there was no significant difference in stroke or death rate in warfarin-treated patients relative to aspirin-treated patients and the confidence intervals were unable to rule out a benefit of one drug over the other (annual rate = 4.7% versus 8.9%, RR = 0.53, 95% CI 0.18 to 1.58). Minor bleeding rates were higher in the cohort of patients who received warfarin (22.9/100 patient-years versus 8.66/100 patient-years, rate ratio = 2.64, p < 0.001). No studies compared medical therapy with surgical or endovascular closure. CONCLUSION: PFO is not associated with increased risk of subsequent stroke or death among medically treated patients with cryptogenic stroke. However, both PFO and ASA possibly increase the risk of subsequent stroke (but not death) in medically treated patients younger than 55 years. In patients with a cryptogenic stroke and an atrial septal abnormality the evidence is insufficient to determine if warfarin or aspirin is superior in preventing recurrent stroke or death, but minor bleeding is more frequent with warfarin. There is insufficient evidence to evaluate the efficacy of surgical or endovascular closure.
Asunto(s)
Aneurisma Cardíaco/epidemiología , Atrios Cardíacos/patología , Defectos del Tabique Interatrial/epidemiología , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/prevención & control , Adulto , Causalidad , Estudios de Cohortes , Comorbilidad , Aneurisma Cardíaco/diagnóstico , Aneurisma Cardíaco/terapia , Defectos del Tabique Interatrial/diagnóstico , Defectos del Tabique Interatrial/terapia , Humanos , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Medición de Riesgo , Prevención SecundariaRESUMEN
BACKGROUND: Previous reports have suggested left hemispheric dominance for maintaining consciousness, although there is controversy over this claim. OBJECTIVE: To compare early impairment of level of consciousness between patients with right and left hemispheric stroke. METHODS: Data from 564 patients with ischaemic stroke enrolled in the placebo arm of a trial of a putative neuroprotectant were analysed. All patients had major hemispheric stroke with cortical dysfunction, visual field deficit, and limb weakness, with symptom onset within 12 hours of enrolment. Patients were prospectively evaluated on a predefined scale (1-6; 1 = fully awake, higher scores representing greater impairment) to measure level of consciousness at multiple time points over the initial 24 hours after presentation. The National Institutes of Health (NIH) stroke scale score at presentation and infarct volume at 30 days were determined. RESULTS: Some degree of impairment in level of consciousness was observed in 409 of the 564 patients (73%). Median maximum sedation score was 2 for both right and left hemispheric stroke (p = 0.91). Mean sedation score over 24 hours was 1.5 for both right and left stroke (p = 0.75). There was no difference between level of consciousness scores in right and left stroke at any individual time point during the 24 hour monitoring period. No association between side and impairment in level of consciousness was seen after adjustment for stroke severity and infarct volume. CONCLUSIONS: In contrast to previous reports, there was no evidence for hemispheric dominance for consciousness in the setting of a major hemispheric stroke.