Sex and Gender Differences in Stroke and Their Practical Implications in Acute Care / 대한뇌졸중학회지

There are several controversies regarding the role of sex and gender in the pathophysiology and management of acute stroke. Assessing the role of sex, i.e., biological/pathophysiological factors, and gender, i.e., sociocultural factors, in isolation is often not possible since they are closely intertwined with each other. To complicate matters even more, the functional baseline status of women and men at the time of their first stroke is substantially different, whereby women have, on average, a poorer reported/ascertained baseline function compared to men. These differences in baseline variables account for a large part of the differences in post-stroke outcomes between women and men. Adjusting for these baseline differences is difficult, and in many cases, residual confounding cannot be excluded. Despite these obstacles, a better understanding of how patient sex and gender differences influence acute stroke and stroke care pathways is crucial to avoid biases and allow us to provide the best possible care for all acute stroke patients. Disregarding patient sex and gender on one hand and ignoring potential confounding factors in sex- and gender-stratified analyses on the other hand, may cause researchers to come to erroneous conclusions and physicians to provide suboptimal care. This review outlines sex- and gender-related factors in key aspects of acute stroke, including acute stroke epidemiology, diagnosis, access to care, treatment outcomes, and post-acute care. We also attempt to outline knowledge gaps, which deserve to be studied in further detail, and practical implications for physicians treating acute stroke patients in their daily practice.

Replacing Alteplase with Tenecteplase: Is the Time Ripe? / 대한뇌졸중학회지

Thrombolysis for acute ischemic stroke has predominantly been with alteplase for over a quarter of a century. In recent years, with trials showing evidence of higher rates of successful reperfusion, similar safety profile and efficacy of tenecteplase (TNK) as compared to alteplase, TNK has now emerged as another potential choice for thrombolysis in acute ischemic stroke. In this review, we will focus on these recent advances, aiming: (1) to provide a brief overview of thrombolysis in stroke; (2) to provide comparisons between alteplase and TNK for clinical, imaging, and safety outcomes; (3) to focus on key subgroups of interest to understand if there is an advantage of using TNK over alteplase or vice-versa, to review available evidence on role of TNK in intra-arterial thrombolysis, as bridging therapy and in mobile stroke units; and (4) to summarize what to expect in the near future from recently completed trials and propose areas for future research on this evolving topic. We present compelling data from several trials regarding the safety and efficacy of TNK in acute ischemic stroke along with completed yet unpublished trials that will help provide insight into these unanswered questions.

Changes in ischemic stroke presentations and associated workflow during the first wave of the COVID-19 pandemic: A population study in Alberta, Canada

BackgroundPandemics may promote hospital avoidance among patients with emergencies, and added precautions may exacerbate treatment delays. There is a paucity of population-based data on these phenomena for stroke. We examined the effect of the COVID-19 pandemic on the presentation and treatment of ischemic stroke in an entire population. MethodsWe used linked provincial administrative data and data from the Quality Improvement and Clinical Research Alberta Stroke Program - a registry capturing stroke-related data on the entire population of Alberta(4.3 million)- to identify all patients presenting with stroke in the pre-pandemic(1-January-2016 to 27-February-2020, n=19,531) and pandemic(28-February-2020 to 30-August-2020, n=2,255) periods. We examined changes in thrombolysis and endovascular therapy(EVT) rates, workflow, and in-hospital outcomes. ResultsHospitalizations/presentations for ischemic stroke dropped (weekly adjusted-incidence-rate-ratio[aIRR]:0.48, 95%CI:0.46-0.50, adjusted for age, sex, comorbidities, pre-admission care needs), as did population-level incidence of thrombolysis(aIRR:0.49,0.44-0.56) or EVT(aIRR:0.59,0.49-0.69). However, the proportions of presenting patients receiving acute therapies did not decline (e.g. thrombolysis:11.7% pre-pandemic vs 13.1% during-pandemic, aOR:1.02,0.75-1.38). Onset-to-door times were prolonged; EVT recipients experienced longer door-to-reperfusion times (median door-to-reperfusion:110-minutes, IQR:77-156 pre-pandemic vs 132.5-minutes, 99-179 during-pandemic; adjusted-coefficient:18.7-minutes, 95%CI:1.45-36.0). Hospitalizations were shorter but stroke severity and in-hospital mortality did not differ. InterpretationThe first COVID-19 wave was associated with a halving of presentations and acute therapy utilization for ischemic stroke at a population level, and greater pre-hospital and in-hospital treatment delays. Our data can inform public health messaging and stroke care in current and future waves. Messaging should encourage attendance for emergencies and stroke systems should re-examine "code stroke" protocols to mitigate inefficiencies.