ORCID Profile
0000-0002-7248-4863
Current Organisations
University of New South Wales
,
Heart Health Research Center
,
National Health and Medical Research Council
,
Royal Prince Alfred Hospital
Does something not look right? The information on this page has been harvested from data sources that may not be up to date. We continue to work with information providers to improve coverage and quality. To report an issue, use the Feedback Form.
Related Links
Publications
Thrombolysis Outcomes in Acute Ischemic Stroke by Fluid-Attenuated Inversion Recovery Hyperintense Arteries
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2020
DOI: 10.1161/STROKEAHA.119.028550
Abstract: To determine factors associated with fluid-attenuated inversion recovery (FLAIR) hyperintense arteries (FLAIR-HAs) on magnetic resonance imaging and their prognostic significance in thrombolysis-treated patients with acute ischemic stroke from the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study) trial alteplase-dose arm. Patients with acute ischemic stroke (N=293) with brain magnetic resonance imaging (FLAIR and diffusion-weighted imaging sequences) scanned .5 hours of symptom onset were assessed for location and extent (score) of FLAIR-HAs, infarct volume, large vessel occlusion (LVO), and other ischemic signs. Logistic regression models were used to determine predictors of FLAIR-HAs and the association of FLAIR-HAs with 90-day outcomes: favorable functional outcome (primary modified Rankin Scale scores, 0–1), other modified Rankin Scale scores, and intracerebral hemorrhage. Prior atrial fibrillation, LVO, large infarct volume, and anterior circulation infarction were independently associated with FLAIR-HAs. The rate of modified Rankin Scale scores 0 to 1 was numerically lower in patients with FLAIR-HAs versus without (69/152 [45.4%] versus 75/131 [57.3%]), as was the subset of LVO (37/93 [39.8%] versus 9/16 [56.3%]), but not in those without LVO (25/36 [69.4%] versus 60/106 [56.6%]). After adjustment for covariables, FLAIR-HAs were independently associated with increased primary outcome (adjusted odds ratio [95% CI]: overall 4.14 [1.63–10.50] with LVO 4.92 [0.87–27.86] no LVO 6.16 [1.57–24.14]) despite an increased risk of hemorrhagic infarct (4.77 [1.12–20.26]). FLAIR-HAs are more frequent in acute ischemic stroke with cardioembolic features and indicate potential for a favorable prognosis in thrombolysis-treated patients possibly mediated by LVO. URL: www.clinicaltrials.gov . Unique identifier: NCT01422616.
Practical neurology: A case-based series
Publisher: AMPCo
Date: 09-2011
DOI: 10.5694/MJA11.10912
Short report: Factors contributing to young people’s susceptibility to e-cigarettes in four countries
Publisher: Elsevier BV
Date: 09-2023
Integrated oral health care for stroke patients – a scoping review
Publisher: Wiley
Date: 07-12-2016
DOI: 10.1111/JOCN.13520
Abstract: To identify current evidence on the role of nurses and allied health professionals in the oral health management of stroke patients, detailing their current knowledge, attitudes and practices and the potential benefits of an integrated oral care programme. Stroke has disabling oral health effects, such as dysphagia and hindered brushing due to upper limb hemiparesis. Together, these can increase bacterial load, increasing risk of pneumonia. In general management of stroke, nurses play a key role in early identification, assessment and referral, while occupational therapists, dieticians and speech pathologists are important in rehabilitation. While this should logically apply to the oral care of stroke patients, there is currently limited information, especially in Australia. Scoping review. A literature search was conducted using multiple databases regarding the oral health management of stroke patients by nondental professionals, and 26 articles were reviewed. The Australian National Clinical Guidelines for Stroke accentuate the need for oral care following stroke and suggest how hospital staff need to be involved. Currently, there are no Australian studies. However, international literature suggests that lack of oral health knowledge by nurses and poor patient attitude are reflected in infrequent assistance with stroke patient oral hygiene. There is limited information regarding the benefits of nursing-driven oral hygiene programme in reducing pneumonia incidence, and only few studies show that involving nurses in assisted oral care reduces plaque. There are some suggestions that involving nurses and speech pathologists in oral rehabilitation can improve dysphagia outcomes. Managing oral health poststroke is vital, and there is a need for an appropriate integrated oral care service in Australia. Nondental professionals, especially nurses, can play a key role in the poststroke oral health management of stroke patients to reduce complications, especially pneumonia.
Self-reported Snoring Patterns Predict Stroke Events in High-Risk Patients With OSA: Post Hoc Analyses of the SAVE Study
Publisher: Elsevier BV
Date: 11-2020
Weekend hospital discharge is associated with suboptimal care and outcomes: An observational Australian Stroke Clinical Registry study
Publisher: SAGE Publications
Date: 22-10-2018
Abstract: The quality of stroke care may diminish on weekends. We aimed to compare the quality of care and outcomes for patients with stroke/transient ischemic attack discharged on weekdays compared with those discharged on weekends. Data from the Australian Stroke Clinical Registry from January 2010 to December 2015 ( n = 45 hospitals) were analyzed. Differences in processes of care by the timing of discharge are described. Multilevel regression and survival analyses (up to 180 days postevent) were undertaken. Among 30,649 registrants, 2621 (8.6%) were discharged on weekends (55% male median age 74 years). Compared to those discharged on weekdays, patients discharged on weekends were more often patients with a transient ischemic attack (weekend 35% vs. 19% p 0.001) but were less often treated in a stroke unit (69% vs. 81% p 0.001), prescribed antihypertensive medication at discharge (65% vs. 71% p 0.001) or received a care plan if discharged to the community (47% vs. 53% p 0.001). After accounting for patient characteristics and clustering by hospital, patients discharged on weekends had a 1 day shorter length of stay (coefficient = −1.31, 95% confidence interval [CI] = −1.52, −1.10), were less often discharged to inpatient rehabilitation (aOR = 0.39, 95% CI = 0.34, 0.44) and had a greater hazard of death within 180 days (hazard ratio = 1.22, 95% CI = 1.04, 1.42) than those discharged on weekdays. Patients with stroke/transient ischemic attack discharged on weekends were more likely to receive suboptimal care and have higher long-term mortality. High quality of stroke care should be consistent irrespective of the timing of hospital discharge.
Rapid Blood Pressure Lowering According to Recovery at Different Time Intervals after Acute Intracerebral Hemorrhage: Pooled Analysis of the INTERACT Studies
Publisher: S. Karger AG
Date: 2015
DOI: 10.1159/000381107
Abstract: b i Background and Purpose: /i /b Early intensive blood pressure (BP) lowering has been shown to improve functional outcome in acute intracerebral hemorrhage (ICH), but the treatment effect is modest and without a clearly defined underlying explanatory mechanism. We aimed at more reliably quantifying the benefits of this treatment according to different time periods in the recovery of participants in the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT) studies. b i Methods: /i /b Pooled analysis of the pilot INTERACT1 (n = 404) and main INTERACT2 (n = 2,839) involving patients with spontaneous ICH ( h) and elevated systolic BP (SBP 150-220 mm Hg) who were randomized to intensive (target SBP mm Hg) or guideline-recommended (target SBP mm Hg) BP lowering treatment. Treatment effects were examined according to repeated measures analysis of an ordinal (‘shift') across all 7 levels of the modified Rankin Scale (mRS) assessed during follow-up at 7, 28, and 90 days, post-randomization. Clinical trial registration information: www.clinicaltrials.gov, NCT00226096 and NCT00716079. b i Results: /i /b Intensive BP lowering resulted in a significant favorable distribution of mRS scores for better functioning (odds ratio 1.13, 95% confidence interval 1.00-1.26 p = 0.042) over 7, 28 and 90 days, and the effect was consistency for early (7-28 days) and later (28-90 days) time periods (p homogeneity 0.353). Treatment effects were also consistent across several pre-specified patient characteristic subgroups, with trends favoring those randomized early, and with higher SBP and milder neurological severity at baseline. b i Conclusions: /i /b Intensive BP lowering provides beneficial effects on physical functioning that manifests consistently through the early and later phases of recovery from ICH.
In adults with acute ICH, intensive BP management did not reduce death or major disability
Publisher: American College of Physicians
Date: 15-10-2013
The PRoFESS trial results: What went wrong?
Publisher: SAGE Publications
Date: 08-2008
Anticoagulants for acute ischaemic stroke
Publisher: Wiley
Date: 22-10-2021
Antithrombotic treatment after stroke due to intracerebral haemorrhage
Publisher: Wiley
Date: 26-01-2023
Sudden limb weakness
Publisher: AMPCo
Date: 05-2012
DOI: 10.5694/MJA12.10441
Abstract: Stroke is a common neurological emergency and may occur in patients of all ages. Rapid assessment is crucial for patients with acute neurological symptoms suggestive of stroke because the opportunity for a positive outcome from thrombolytic treatment diminishes rapidly within the first few hours. Although plain non-contrast computed tomography of the brain is adequate to exclude haemorrhage and conditions such as malignancy, advanced multimodal imaging can be used to assist with decision making regarding the use of recombinant tissue plasminogen activator and mechanical clot-retrieval approaches without adding significant delay. Excellent outcomes are possible with the early use of reperfusion therapies, even when large areas of brain ischaemia are present, provided that there is evidence of potentially salvageable brain and that treatment can commence without unnecessary delay and hazard.
Early supported discharge after stroke
Publisher: Medical Journals Sweden AB
Date: 2007
Abstract: Patients after stroke conventionally receive much of their rehabilitation in hospital. Services have been developed that offer patients an early discharge from hospital with more rehabilitation at home (early supported discharge). This paper sets out a systematic review of all randomized trials of early supported discharge services that included 12 trials (1659 patients). There was a reduced odds of death or dependency equivalent to 5 fewer adverse outcomes (95% confidence interval 1-10) for every 100 patients receiving an early supported discharge service (p = 0.04). Patients receiving early supported discharge services showed an 8 day reduction (p < 0.0001) in the length of hospital stay. The greatest benefits were seen in the trials evaluating a co-ordinated multidisciplinary early supported discharge team and with patients with mild-moderate disability. The experience of a trial from Stockholm is described in order to explore the potential mechanism of action of early supported discharge services. In conclusion, an illustrative case report is set out, indicating a typical patient pathway in an early supported discharge service.
The epidemiology is promising, but the trial evidence is weak. Why pharmacological dementia risk reduction trials haven't lived up to expectations, and where do we go from here?
Publisher: Wiley
Date: 02-11-2022
DOI: 10.1002/ALZ.12393
Abstract: There is an urgent need for interventions that can prevent or delay cognitive decline and dementia. Decades of epidemiological research have identified potential pharmacological strategies for risk factor modification to prevent these serious conditions, but clinical trials have failed to confirm the potential efficacy for such interventions. Our multidisciplinary international group reviewed seven high-potential intervention strategies in an attempt to identify potential reasons for the mismatch between the observational and trial results. In considering our findings, we offer constructive recommendations for the next steps. Overall, we observed some differences in the observational evidence base for the seven strategies, but several common methodological themes that emerged. These themes included the appropriateness of trial populations and intervention strategies, including the timing of interventions and other aspects of trials methodology. To inform the design of future clinical trials, we provide recommendations for the next steps in finding strategies for effective dementia risk reduction.
Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysis
Publisher: Elsevier BV
Date: 05-2021
Comparative effects of intensive-blood pressure versus standard-blood pressure-lowering treatment in patients with severe ischemic stroke in the ENCHANTED trial
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-10-2021
Stroke service: How can we improve and measure outcomes? Consensus summary from a global stroke forum
Publisher: Hindawi Limited
Date: 03-05-2014
DOI: 10.1111/ANE.12256
Abstract: The success of acute stroke treatment is first and foremost time-dependent, and the need for improvement in acute stroke management is demonstrated by the fact that only a minority of patients gain access to treatment - in particular, intravenous recombinant tissue plasminogen activator (IV tPA) - within the necessary time window. Standards of acute stroke care vary widely both regionally and nationally consequently, various healthcare organizations have undertaken initiatives to measure and improve quality of care. To date, most quality measures have been process-based, focusing primarily on metrics of patient care in the acute hospital-based setting (e.g., time to recombinant tPA administration). Therefore, there remains a need for metrics designed to assess how improvements in process translate into patient outcomes. A global forum was convened to share best practice and provide consensus recommendations on core metrics for measuring improvements in access to care and patient outcomes. Recommendations for core metrics of patient outcomes include hospital-based outcomes (e.g., neurological status at 24 h, ambulatory status at discharge) and post-discharge outcomes (e.g., modified Rankin Scale score at 30 and/or 90 days). Recommendations for best practice relating to aspects of people, process, and technology involved in the stroke treatment pathway that may help provide improvements in these core outcome measures are also outlined.
Hospital Presentations in Long-Term Survivors of Stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2020
DOI: 10.1161/STROKEAHA.120.030656
Abstract: A comprehensive understanding of the long-term impact of stroke assists in health care planning. We aimed to determine changes in rates, causes, and associated factors for hospital presentations among long-term survivors of stroke. Person-level data from the AuSCR (Australian Stroke Clinical Registry) during 2009 to 2013 were linked with state-based health department emergency department and hospital admission data. The study cohort included adults with first-ever stroke who survived the first 6 months after discharge from hospital. Annualized rates of hospital presentations (nonadmitted emergency department or admission) erson/year were calculated for 1 to 12 months prior, and 7 to 12 months (inclusive) after hospitalization. Multilevel, negative binomial regression was used to identify associated factors after adjustment for prestroke hospital presentations and stratification for perceived impairment status. Perceived impairments to health were defined according to the subscales and visual analog health status scores on the 5-Dimension European Quality of Life Scale. There were 7183 adults with acute stroke, 7-month survivors (median age 72 years 56% male 81% ischemic, and 42% with impairment at 90–180 days) from 39 hospitals included in this landmark analysis. Annualized presentations erson increased from 0.88 (95% CI, 0.86–0.91) to 1.25 (95% CI, 1.22–1.29) between the prestroke and poststroke periods, with greater rate increases in those with than without perceived impairment (55% versus 26%). Higher presentation rates were most strongly associated with older age (≥85 versus 65 years, incidence rate ratio, 1.52 [95% CI, 1.27–1.82]) and greater comorbidity score (incidence rate ratio, 1.06 [95% CI, 1.02–1.10]), whereas reduced rates were associated with greater social advantage (incidence rate ratio, 0.71 [95% CI, 0.60–0.84]). Poststroke hospital presentations (7–12 months) were most frequently related to recurrent cardiovascular and cerebrovascular events and sequelae of stroke. A large increase in annualized hospital presentation rates after stroke indicates the potential for improved community management and support for this vulnerable patient group.
Statistical analysis plan for evaluating different intensities of blood pressure control in the ENhanced Control of Hypertension And Thrombolysis strokE stuDy.
Publisher: SAGE Publications
Date: 09-10-2018
Abstract: The ENhanced Control of Hypertension And Thrombolysis strokE study (ENCHANTED) trial was initiated as a 2 × 2 partial-factorial active-comparison, prospective, randomized, open, blinded endpoint clinical trial to evaluate in thrombolysis-eligible acute ischemic stroke (AIS) patients whether: (1) Arm A – low-dose (0.6 mg/kg body weight) intravenous (iv) alteplase has noninferior efficacy and lower risk of symptomatic intracerebral hemorrhage (sICH) compared with standard-dose (0.9 mg/kg body weight) iv alteplase and (2) Arm B – early intensive blood pressure (BP) lowering (systolic target 130–140 mmHg) has superior efficacy and lower risk of ICH compared with guideline-recommended BP control (systolic target mmHg). Arm A was completed in 2016 Arm B is now concluding. To outline in detail and make public the predetermined statistical analysis plan (SAP) for the ‘BP control’ arm of this study. All data collected by participating researchers will be reviewed and formally assessed. Information pertaining to the baseline characteristics of patients, their process of care, and the delivery of treatments will be outlined, and for each item, statistically relevant descriptive elements will be described. For the trial outcomes, the most appropriate statistical comparisons to be made between groups are planned and described. A SAP was developed for the results of the BP control arm of this study that is transparent, available to the public, verifiable, and predetermined before completion of data collection. We have developed a predetermined SAP for the ENCHANTED BP control arm to be followed to avoid analysis bias arising from prior knowledge of the study findings. ClinicalTrials.gov (NCT01422616) ISRCTN Register (ISRCTN82387104) Australian New Zealand Clinical Trial Registry (ACTRN12611000236998) EU Clinical Trials Register (2011-005545-12) and Clinical Trials Registry – India (REF/2017/05/014334).
Pharmaceutical Interventions for Emotionalism After Stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2010
Ten-year risk of first recurrent stroke and disability after first-ever stroke in the Perth Community Stroke Study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2004
DOI: 10.1161/01.STR.0000116183.50167.D9
Abstract: Background and Purpose— Limited information exists on the long-term prognosis after first-ever stroke. We aimed to determine the absolute frequency of first recurrent stroke and disability and the relative frequency of recurrent stroke over 10 years after first-ever stroke in Perth, Western Australia. Methods— For a 12-month period beginning February 1989, all in iduals with suspected acute stroke or transient ischemic attack who lived in a geographically defined and representative region of Perth were registered prospectively. Patients with a definite first-ever stroke were followed up 10 years after the index event. Results— Over 10 years of follow-up, the cumulative risk of a first recurrent stroke was 43% (95% confidence interval [CI], 34 to 51). After the first year after first-ever stroke, the average annual risk of recurrent stroke was ≈4%. Case fatality at 30 days after first recurrent stroke was 41%, which was significantly greater than the case fatality at 30 days after first-ever stroke (22%) ( P =0.003). For 30-day survivors of first-ever stroke, the 10-year cumulative risk of death or new institutionalization was 79% (95% CI, 73 to 85) and of death or new disability was 87% (95% CI, 81 to 92). Conclusions— Over 10 years of follow-up, the risk of first recurrent stroke is 6 times greater than the risk of first-ever stroke in the general population of the same age and sex, almost one half of survivors remain disabled, and one seventh require institutional care. Effective strategies for prevention of stroke need to be implemented early, monitored frequently, and maintained long term after first-ever stroke.
Long-Term Disability After First-Ever Stroke and Related Prognostic Factors in the Perth Community stroke Study, 1989-1990
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2002
DOI: 10.1161/01.STR.0000012515.66889.24
Abstract: Background and Purpose — Few reliable estimates of the long-term functional outcome after stroke are available. This population-based study aimed to describe disability, dependency, and related independent prognostic factors at 5 years after a first-ever stroke in patients in Perth, Western Australia. Methods — All in iduals with a suspected acute stroke who were resident in a geographically defined region (population, 138 708) of Perth, Western Australia, were registered prospectively and assessed according to standardized diagnostic criteria over a period of 18 months in 1989 to 1990. Patients were followed up prospectively at 4 and 12 months and 5 years after the index event. Results — There were 370 cases of first-ever stroke, and 277 patients survived to 30 days. Of these early survivors, 152 (55%) were alive at 5 years, and among those who were neither institutionalized (n=146) nor disabled (n=129) at the time of their stroke, 21 (14%) were institutionalized in a nursing home, and 47 (36%) were disabled. The most important predictors of death or disability at 5 years were increasing age, baseline disability defined by a Barthel Index score of /20 (odds ratio [OR], 6.3 95% confidence interval [CI], 2.7 to 14), moderate hemiparesis (OR, 2.7 95% CI, 1.1 to 6.2), severe hemiparesis (OR, 4.5 95% CI, 1.1 to 19), and recurrent stroke (OR, 9.4 95% CI, 3.0 to 30). A low level of activity before the stroke was a significant predictor of institutionalization, and subsequent recurrent stroke was a consistent, independent predictor of institutionalization, disability, and death or institutionalization, increasing the odds of each of these 3 adverse outcomes by 5- to 15-fold. Conclusions — Among 30-day survivors of first-ever stroke, about half survive 5 years of survivors, one third remain disabled, and 1 in 7 are in permanent institutional care. The major modifiable predictors of poor long-term outcome are a low level of activity before the stroke and subsequent recurrent stroke. Efforts to increase physical activity among the elderly and to prevent recurrent stroke in survivors of a first stroke are likely to reduce the long-term burden of cerebrovascular disease.
Degree and Timing of Intensive Blood Pressure Lowering on Hematoma Growth in Intracerebral Hemorrhage: Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial-2 Results.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2016
DOI: 10.1161/STROKEAHA.116.013326
Abstract: Degree and timing of blood pressure (BP) lowering treatment in relation to hematoma growth were investigated in the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial-2 (INTERACT2). INTERACT2 was an international clinical trial of intensive (target systolic BP [SBP], mm Hg) versus guideline-recommended (SBP, mm Hg) BP lowering in 2839 patients within 6 hours of spontaneous intracerebral hemorrhage and elevated SBP (150–220 mm Hg), in which 964 had repeat cranial computed tomography at 24 hours. ANCOVA models assessed categories of SBP reduction and time to target SBP on 24-hour hematoma growth. Greater SBP reduction was associated with reduced hematoma growth (13.3, 5.0, and 3.0 mL for , 10–20, and ≥20 mm Hg, respectively P trend .001). In the intensive treatment group (n=491), the least mean hematoma growth was in patients who achieved target SBP hour (2.6 mL) versus to those in target at 1 to 6 (4.7 mL) and hours (5.4 mL). The smallest mean absolute hematoma growth (2.0 mL) was in those achieving target SBP 5 to 8 times versus 3 to 4 (3.1 mL) and 0 to 2 times (5.2 mL). Intensive BP lowering with greater SBP reduction, which is achieved quickly and maintained consistently, seems to provide protection against hematoma growth for 24 hours. URL: www.clinicaltrials.gov . Unique identifier: NCT00716079.
Patterns of acute hospital care, rehabilitation, and discharge disposition after acute stroke: The perth community stroke study 1989-1990
Publisher: S. Karger AG
Date: 1994
DOI: 10.1159/000108506
Timing of blood pressure lowering in acute ischemic stroke.
Publisher: Springer Science and Business Media LLC
Date: 04-06-2015
DOI: 10.1007/S11883-015-0520-Y
Abstract: Whether there are any benefits without harm from early lowering of blood pressure (BP) in the setting of acute ischemic stroke (AIS) has been a longstanding controversy in medicine. Whilst most studies have consistently shown associations between elevated BP, particularly systolic BP, and poor outcome, some also report that very low BP (systolic <130 mmHg) and large reductions in systolic BP are associated with poor outcomes in AIS. However, despite these associations, the observed U- or J-shaped relationship between BP and outcome in these patients may not be causally related. Patients with more severe strokes may have a more prominent autonomic response and later lower BP as their condition worsens, often pre-terminally. Fortunately, substantial progress has been made in recent years with new evidence arising from well-conducted randomized trials. This review outlines new evidence and recommendations for clinical practice over BP management in AIS.
Lower blood pressure and risk of recurrent stroke in patients with chronic kidney disease: PROGRESS trial
Publisher: Elsevier BV
Date: 04-2008
DOI: 10.1038/KI.2008.5
Abstract: Recent epidemiological studies have shown a J-shaped association between the risk of stroke and systolic blood pressure (SBP) levels in people with chronic kidney disease (CKD). The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) was a randomized, placebo-controlled trial demonstrating that perindopril-based blood pressure (BP) lowering reduced the risk of stroke in 6105 participants with prior cerebrovascular disease. We estimated the effects of therapy on the risk of recurrent stroke in 1757 of these participants with stage 3 or greater CKD according to baseline BP and the relationship between achieved follow-up BP and the risk of stroke. Active therapy produced comparable and significant reductions in the risk of stroke across all baseline SBP levels. The age- and gender-adjusted incidence of stroke increased significantly in a log-linear relationship for achieved SBP levels and strokes per 1000 person-years. This association persisted after adjusting for potential confounding factors. We found that perindopril-based BP lowering effectively prevented recurrent stroke in people with CKD, across a wide range of BP levels, without evidence of an increased risk of stroke in people with low BP levels.
Modifiable lifestyle behaviours account for most cases of subarachnoid haemorrhage: A population-based case–control study in Australasia
Publisher: Elsevier BV
Date: 02-2012
DOI: 10.1016/J.JNS.2011.09.017
Abstract: Smoking, hypertension and alcohol excess are the major causal risk factors for subarachnoid haemorrhage (SAH) that are modifiable. We aimed to explore the hypothesis that other modifiable lifestyle factors, such as diet, may also underpin a substantial proportion of the population attributable risk (PAR) of SAH. In a multi-centre, population-based, case-control study, information on smoking status, history of hypertension, physical activity, dietary intake, alcohol consumption, body mass index, and family history of SAH, were obtained from 432 incident SAH cases and 473 frequency-matched community-based SAH-free controls without SAH. Multivariate analysis was used to identify significant risk factors and associated PARs for SAH, reported with 95% confidence intervals (CI). Smoking and history of hypertension accounted for 30% (95%CI 23-37%) and 21% (10-30%) of SAH, respectively. Additionally, 25% (11-37%) of SAH was attributed to drinking skim or reduced fat milk, 15% (5-24%) to eating fruit less than once weekly, and 13% (5-21%) to eating either the fat on meat or skin on chicken >4 times weekly. Alcohol excess was not associated with SAH. Smoking cessation and blood pressure control are the most important strategies to prevent SAH. However, drinking skimmed/reduced fat milk, eating fruits regularly, and removing the fat from meats and skin from chicken before consumption may also reduce the burden of SAH.
Trends in recruitment of women and reporting of sex differences in large-scale published randomized controlled trials in stroke
Publisher: SAGE Publications
Date: 27-05-2019
Abstract: Understanding of sex differences, especially in terms of the influence of sex on therapeutic interventions, can lead to improved treatment and management for all. We examined temporal and regional trends in female participation and the reporting of sex differences in stroke randomized controlled trials. Randomized controlled trials from 1990 to 2018 were identified from ClinicalTrials.gov, using keywords “stroke” and “cerebrovascular accidents.” Studies were selected if they enrolled ≥100 participants, included both sexes and were published trials (identified using PubMed, Google Scholar, and Scopus). Of 1700 stroke randomized controlled trials identified, 277 were published and eligible for analysis. Overall, these randomized controlled trials enrolled only 40% females, and in the past 10 years, this percentage barely changed, peaking at 41% in 2008–2009 and 2012–2013. North American randomized controlled trials recruited the most women, at 43%, and Asia the lowest, at 40%. Among the 277 randomized controlled trials, 101 (36%) reported results according to sex, of which 91 (33%) were pre-specified analyses. The increasing trend in the number of studies reporting sex-differentiated results from 2008 to 2018 merely paralleled the increase in the number of papers published during the same time period. North American randomized controlled trials most often reported sex-specific results (42%), and Australia and Europe least often (31%). Little progress has been made in the inclusion of females and the reporting of sex in stroke randomized controlled trials. This highlights the need for key stakeholders, such as funders and journal editors, to provide clear guidance and effective implementation strategies to researchers in the scientific reporting of sex.
The association between functional status and physical pain with depressive symptoms after a stroke event: A cross-sectional analysis of the China Health and Retirement Longitudinal Study 2018
Publisher: Frontiers Media SA
Date: 12-09-2022
DOI: 10.3389/FPSYT.2022.927856
Abstract: Stroke is a major cause of mortality and long-term physical and cognitive impairment. This study aims to: (1) examine the prevalence of depressive symptoms, disability and pain among Chinese adults with stroke (2) test the associations of functional limitations and body pain with occurrence of depressive symptoms (3) investigate gender and urban-rural disparities in these associations. This study utilized the data from the China Health and Retirement Longitudinal Study in 2018, involving 969 patients with stroke among 17,970 participants aged ≥ 45 years. Depressive symptoms were assessed using the 10-item Center for Epidemiologic Studies Depression (CES-D) Scale. We performed multivariable logistic regression models to estimate the associations between activities of daily life (ADL), instrumental activities of daily life (IADL) and pain with depressive symptoms. Depressive symptoms were found among 40.2% of stroke patients, with a higher prevalence in females (48.2%) than males (32.7%). Prevalence of ADL limitations, IADL limitations and pain among stroke patients were 39.2, 49.8 and 14.0%, respectively. ADL and IADL limitations and pain were more prevalent among females and residents in rural areas. Multivariable regression analyses showed a significant association between ADL limitation (OR = 1.535, 95% CI = 1.168, 2.018), IADL limitation (OR = 1.666, 95% CI = 1.260, 2.203) and pain (OR = 2.122, 95% CI = 1.466, 3.073) with depressive symptoms. Stratified analyses revealed stronger associations among urban residents. Females had a higher association of ADL and IADL with depressive symptoms but similar in that of pain to the males. The impact of ADL and IADL in male patients is higher than in females, but the impact of pain on depressive symptoms is higher in female patients. Depressive symptoms are common amongst post-stroke patients in China and are significantly associated with functional disability and physical pain. Our findings have implications for practitioners on the early assessment of pain and depression after stroke. Future research should explore effective intervention measures for physical-mental stroke complications.
Pharmaceutical Interventions for Emotionalism After Stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2004
NOR-TEST-ing tenecteplase in acute ischaemic stroke
Publisher: Elsevier BV
Date: 10-2017
Low- Versus Standard-Dose Alteplase in Patients on Prior Antiplatelet Therapy: The ENCHANTED Trial (Enhanced Control of Hypertension and Thrombolysis Stroke Study).
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2017
DOI: 10.1161/STROKEAHA.116.016274
Abstract: Many patients receiving thrombolysis for acute ischemic stroke are on prior antiplatelet therapy (APT), which may increase symptomatic intracerebral hemorrhage risk. In a prespecified subgroup analysis, we report comparative effects of different doses of intravenous alteplase according to prior APT use among participants of the international multicenter ENCHANTED study (Enhanced Control of Hypertension and Thrombolysis Stroke Study). Among 3285 alteplase-treated patients (mean age, 66.6 years 38% women) randomly assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) intravenous alteplase within 4.5 hours of symptom onset, 752 (22.9%) reported prior APT use. Primary outcome at 90 days was the combined end point of death or disability (modified Rankin Scale [mRS] scores, 2–6). Other outcomes included mRS scores 3 to 6, ordinal mRS shift, and symptomatic intracerebral hemorrhage by various standard criteria. There were no significant differences in outcome between patients with and without prior APT after adjustment for baseline characteristics and management factors during the first week defined by mRS scores 2 to 6 (adjusted odds ratio [OR], 1.01 95% confidence interval [CI], 0.81–1.26 P =0.953), 3 to 6 (OR, 0.95 95% CI, 0.75–1.20 P =0.662), or ordinal mRS shift (OR, 1.03 95% CI, 0.87–1.21 P =0.770). Alteplase-treated patients on prior APT had higher symptomatic intracerebral hemorrhage (OR, 1.82 95% CI, 1.00–3.30 P =0.051) according to the safe implementation of thrombolysis in stroke-monitoring study definition. Although not significant ( P -trend, 0.053), low-dose alteplase tended to have better outcomes than standard-dose alteplase in those on prior APT compared with those not using APT (mRS scores of 2–6 OR, 0.84 95% CI, 0.62–1.12 versus OR, 1.16 95% CI, 0.99–1.36). Low-dose alteplase may improve outcomes in thrombolysis-treated acute ischemic stroke patients on prior APT, but this requires further evaluation in a randomized controlled trial. URL: www.clinicaltrials.gov . Unique identifier: NCT01422616.
Management of Depression After Stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2005
DOI: 10.1161/01.STR.0000162391.27991.9D
Abstract: Background and Purpose— Although depression may affect recovery and outcome after stroke, it is often overlooked or inadequately managed, and there is uncertainty regarding the benefits of antidepressant therapy in this setting. We aimed to assess the effectiveness of antidepressants for the treatment and prevention of depression after stroke. Methods— We undertook a systematic review using Cochrane methods of randomized placebo-controlled trials of antidepressants for the treatment or prevention of depressive illness and “abnormal mood” after stroke. Treatment effects on physical and other outcomes were also examined. Results— Outcome data were available for 7 treatment trials including 615 patients and 9 prevention trials including 479 patients. Because of the considerable variation in research design, trial quality, and method of reporting across studies, we did not pool all the outcome data. In the treatment trials, antidepressants reduced mood symptoms but had no clear effect on producing a remission of diagnosable depressive illness. There was no definitive evidence that antidepressants prevent depression or improve recovery after stroke. Conclusions— There is insufficient randomized evidence to support the routine use of antidepressants for the prevention of depression or to improve recovery from stroke. Although antidepressants may improve mood in stroke patients with depression, it is unclear how clinically significant such modest effects are in patients other than those with major depression. There is a pressing need for further research to better define the role of antidepressants in stroke management.
E-cigarette-related beliefs, behaviors, and policy support among young people in China
Publisher: E.U. European Publishing
Date: 23-01-2023
DOI: 10.18332/TID/156836
INTEnsive ambulance-delivered blood pressure Reduction in hyper-ACute stroke Trial (INTERACT4): study protocol for a randomized controlled trial
Publisher: Springer Science and Business Media LLC
Date: 12-2021
DOI: 10.1186/S13063-021-05860-Y
Abstract: Early pre-hospital initiation of blood pressure (BP) lowering could improve outcomes for patients with acute stroke, by reducing hematoma expansion in intracerebral hemorrhage (ICH), and time to reperfusion treatment and risk of intracranial hemorrhage in ischemic stroke (IS). We present the design of the fourth INTEnsive ambulance-delivered blood pressure Reduction in hyper-ACute stroke Trial (INTERACT4). A multi-center, ambulance-delivered, prospective, randomized, open-label, blinded endpoint (PROBE) assessed trial of pre-hospital BP lowering in 3116 hypertensive patients with suspected acute stroke at 50+ sites in China. Patients are randomized through a mobile phone digital system to intensive BP lowering to a target systolic BP of 140 mmHg within 30 min, or guideline-recommended BP management according to local protocols. After the collection of in-hospital clinical and management data and 7-day outcomes, trained blinded assessors conduct telephone or face-to-face assessments of physical function and health-related quality of life in participants at 90 days. The primary outcome is the physical function on the modified Rankin scale at 90 days, analyzed as an ordinal outcome with 7 categories. The s le size was estimated to provide 90% power ( α = 0.05) to detect a 22% reduction in the odds of a worse functional outcome using ordinal logistic regression. INTERACT4 is a pragmatic clinical trial to provide reliable evidence on the effectiveness and safety of ambulance-delivered hyperacute BP lowering in patients with suspected acute stroke. ClinicalTrials.gov NCT03790800. Registered on 2 January 2019 Chinese Trial Registry ChiCTR1900020534. Registered on 7 January 2019. All items can be found in this protocol paper.
Atorvastatin combined with dexamethasone in chronic subdural haematoma (ATOCH II): study protocol for a randomized controlled trial
Publisher: Springer Science and Business Media LLC
Date: 12-2021
DOI: 10.1186/S13063-021-05871-9
Abstract: Chronic subdural haematoma (CSDH) is a common condition in the elderly that often requires neurosurgical management. For small CSDH, evidence has emerged that statins may reduce haematoma volume and improve outcomes, presumably by reducing local inflammation and promoting vascular repair. We wish to extend this evidence in a study that aims to determine the efficacy and safety of atorvastatin combined with low-dose dexamethasone in patients with CSDH. The second ATorvastatin On Chronic subdural Hematoma (ATOCH-II) study is a multi-centre, randomized, placebo-controlled, double-blind trial which aims to enrol 240 adult patients with a conservative therapeutic indication for CSDH, randomly allocated to standard treatment with atorvastatin 20 mg combined with low-dose dexamethasone (or matching placebos) daily for 28 days, and with 152 days of follow-up. The primary outcome is a composite good outcome defined by any reduction from baseline in haematoma volume and survival free of surgery at 28 days. Secondary outcomes include functional outcome on the modified Rankin scale (mRS) and modified Barthel Index at 28 days, surgical transition and reduction in haematoma volumes at 14, 28 and 90 days. This multi-centre clinical trial aims to provide high-quality evidence on the efficacy and safety of the combined treatment of atorvastatin and low-dose dexamethasone to reduce inflammation and enhance angiogenesis in CSDH. ChiCTR, ChiCTR1900021659 . Registered on 3 March 2019, www.chictr.org.cn/showproj.aspx?proj=36157 .
Design of the CHina Epidemiology Research in Subarachnoid Haemorrhage (CHERISH) study
Publisher: SAGE Publications
Date: 03-11-2010
DOI: 10.1111/J.1747-4949.2010.00521.X
Abstract: Limited epidemiological data exist on subarachnoid haemorrhage (SAH) in China. Effective prevention requires knowledge of the rates and risk factors for SAH the most lethal type of stroke that most often affects younger adults. We report the methods and the initial experience of a new study to address this deficiency. To determine the incidence, risk factors, management and outcomes of SAH. The CHina Epidemiology Research In Subarachnoid Haemorrhage (CHERISH) is a prospective, population-based, case–control study in a defined region (study population 1.7 million) of the city of Baotou in Inner Mongolia, China. Cases of spontaneous SAH are identified using standard definitions through prospective surveillance of all major acute care hospitals with neurology/neurosurgery facilities, small hospitals/clinics, and the single city crematorium over a 2-year period. Verbal autopsy procedures are used to ascertain the probable causes of deaths outside of hospital. For each case, two nonrelative controls without SAH are matched by age (5-year strata), gender, and district of residence. Data are collected on socio-demography, lifestyle factors, and medical history, and blood is taken for the extraction and storage of DNA. Details of the clinical features, presentation, and management of SAH are obtained from cases, and survivors provide details on health care utilisation, physical function, health-related quality of life, and complications, at 6-months. The primary outcomes are overall, age- and gender-specific incidence, relative (odds ratios) and population-attributable risks for defined exposures, and 28-day and 6-month case fatality ratios and other outcomes. Preliminary experience confirms the completeness of the surveillance methods, with no clear missed out-of-hospital cases of SAH with sudden death, and of high participation and reliable data collection procedures. CHERISH is well placed to provide reliable estimates of the burden of SAH in China.
Prevalence of Driving and Traffic Accidents among People with Seizures: A Systematic Review
Publisher: S. Karger AG
Date: 2019
DOI: 10.1159/000500599
Abstract: b i Background and Objectives: /i /b Epilepsy influences the ability to drive. We undertook a systematic review to determine the prevalence of driving or holding a driver’s license among people with seizures, the prevalence of traffic accidents among those who drive, and factors that may explain heterogeneity in these point estimates. b i Method: /i /b We followed MOOSE and PRISMA guidelines in searching 8 databases from inception to June 27, 2018. All published observational studies were included, with the exception of case-control studies where prevalence could not be determined, case reports, and studies with fewer than 50 participants. We assessed external and internal validity and quality of studies, produced forest plots, and conducted meta-regression in “Stata 13.” b i Results: /i /b Data were available from 67 studies published between 1967 and 2018. Across the studies there was a wide range in the prevalence of driving (3–90%) and holding a driver’s license (8–98%). Up to 39% of people with epilepsy drove in violation of restrictions. Prevalence of traffic accidents ranged from 0 to 61% following seizure onset, or in the past 1–5 years. The percentage of people with seizures who drove decreased as time since diagnosis increased ( i /i = 0.01, adjusted i R /i sup /sup = 31%). The number of people with seizures who drove or held a driver’s license appears to have increased over time ( i /i = 0.02, adjusted i R /i sup /sup = 7%) but without a corresponding increase in the number of traffic accidents. There was considerable heterogeneity between studies related to definitions, design, and population differences. b i Conclusions: /i /b There is considerable variation in the prevalence of driving after a diagnosis of epilepsy and in reported motor vehicle accidents. Further efforts are required to better understand the impact of epilepsy, and epilepsy surgery, on driving and road safety, especially where driving continues in violation of restrictions. Policy changes are needed to encourage the introduction of available and affordable alternatives for driving, for ex le, developing public transport networks, and promoting subsidy schemes to encourage use of public transport, taxis, Uber, and Lyft, among people experiencing seizures.
Evolution of Practice During the Interventional Management of Stroke III Trial and Implications for Ongoing Trials
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2014
DOI: 10.1161/STROKEAHA.114.005952
Abstract: We explored changes in the patient population and practice of endovascular therapy during the course of the Interventional Management of Stroke (IMS) III Trial. Changes in baseline characteristics, use of baseline CT angiography, treatment times and specifics, and outcomes were compared between the first 4 protocols and the fifth and final protocol. Compared with subjects treated in the first 4 protocol versions (n=610), subjects treated in fifth and final protocol (n=46) were older (75 versus 68 years, P .0002) and less likely to have a pretreatment Rankin of 0 (76% versus 89%, P =0.01), were more likely to have a pretreatment CT angiography (65% versus 45%, P =0.009), had quicker median times in the endovascular arm from onset to start of intra-arterial therapy (209 versus 250 minutes, P =0.002) and to reperfusion (269 versus 344 minutes, P .0001), had a higher mean dose of total tissue-type plasminogen activator in the endovascular arm (74.0 versus 63.7 mg, P .0001), and were less likely to receive intra-arterial tissue-type plasminogen activator as part of the endovascular procedure (16% versus 44%, P =0.015). There were no significant differences in functional and safety outcomes between subjects treated in the 2 treatments arms in either the first 4 protocols or fifth protocol although the small s le size in the fifth protocol provided limited power. Endovascular technology and diagnostic approaches to acute stroke patients changed substantially during the IMS III Trial. Efforts to decrease the time to delivery of endovascular therapy were successful.
Systematic review of coexistent epileptic seizures and Alzheimer's disease: Incidence and prevalence
Publisher: Wiley
Date: 19-03-2021
DOI: 10.1111/JGS.17101
Abstract: Coexistent seizures add complexity to the burden of Alzheimer's disease (AD). We aim to estimate the incidence and prevalence of coexistent seizures and AD and summarize characteristics. A systematic review and meta‐analysis (PROSPERO protocol registration CRD42020150479). Population‐, community‐, hospital‐, or nursing home‐based. Thirty‐nine studies reporting on seizure incidence and prevalence in 21,198 and 380,777 participants with AD, respectively, and AD prevalence in 727,446 participants with seizures. When statistical heterogeneity and inconsistency (assessed by Q statistic and I 2 ) were not shown, rates were synthesized using random effect. Studies were conducted in Australia, Brazil, Finland, France, Ireland, Italy, Japan, Netherlands, Portugal, Sweden, Taiwan, United Kingdom, and United States. The incidence of seizures among people with clinically diagnosed AD ranged from 4.2 to 31.5 per 1000 person‐years. Prevalence of seizures among people with clinically diagnosed AD ranged from 1.5% to 12.7% generally, but it rose to the highest (49.5% of those with early‐onset AD) in one study. Meta‐analysis reported a combined seizure prevalence rate among people with pathologically verified AD at 16% (95% confidence interval [CI] 14–19). Prevalence of seizure in autosomal dominant AD (ADAD) ranged from 2.8% to 41.7%. Being younger was associated with higher risk of seizure occurrence. Eleven percent of people with adult‐onset seizures had AD (95%CI, 7‐14). Seizures are common in those with AD, and seizure monitoring may be particularly important for younger adults and those with ADAD.
Antihypertensive treatment and risk of cancer: an individual participant data meta-analysis
Publisher: Elsevier BV
Date: 04-2021
A randomized controlled trial on rehabilitation through caregiver-delivered nurse-organized service programs for disabled stroke patients in rural china (the RECOVER trial): design and rationale
Publisher: SAGE Publications
Date: 28-07-2016
Abstract: Stroke is the leading cause of death and disability in rural China. For stroke patients residing in resource-limited rural areas, secondary prevention and rehabilitation are largely unavailable, and where present, are far below evidence-based standards. This study aims to develop and implement a simplified stroke rehabilitation program that utilizes nurses and family caregivers for service delivery, and evaluate its feasibility and effectiveness in rural China. This 2-year randomized controlled trial is being conducted in 2–3 county hospitals located in northwest, northeast, and southwest China. Eligible and consenting stroke inpatients (200 in total) have been recruited and randomized into either a control or intervention group. Nurses in the county hospital are trained by rehabilitation specialists and in turn train the family caregivers in the intervention group. They also provide telephone follow-up care three times post discharge. The recruitment, baseline, intervention, follow-up care, and evaluation are guided by the RECOVER mobile phone app specifically designed for this study. The primary outcome is patients’ Barthel Index (activities of daily living: mobility, self-care, and toileting) at 6 months. Process and economic evaluation will also be conducted. The results of our study will generate initial high-quality evidence to improve stroke care in resource-scarce settings. If proven effective, this innovative care delivery model has the potential to improve the health and function of stroke patients, relieve caregiver burden, guide policy-making, and advance translational research in the field of stroke care.
A Consensus on Stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2011
DOI: 10.1161/STROKEAHA.110.606285
Abstract: Research evidence supporting Early Supported Discharge (ESD) services has been summarized in a Cochrane Systematic Review. Trials have shown that ESD can reduce long-term dependency and admission to institutional care and reduce the length of hospital stay. No adverse impact on the mood or well-being of patients or carers has been reported. With the implementation of many national and international stroke initiatives, we felt it timely to reach consensus about ESD among trialists who contributed to the review. We used a modified Delphi approach with 10 ESD trialists. An agreed list of statements about ESD was generated from the Cochrane review and three rounds of consultation completed. ESD trialists rated statements regarding team composition, model of team work, intervention, and success. Consensus of opinion ( % agreement) was obtained on 47 of the 56 statements. Multidisciplinary, specialist stroke ESD teams should plan and co-ordinate both discharge from hospital and provide rehabilitation in the community. Specific eligibility criteria (safety, practicality, medical stability, and disability) need to be followed to ensure this service is provided for mild to moderate stroke patients who can benefit from ESD. Length of stay in hospital, patient and carer outcome measures and cost, need to be routinely audited. We have created a consensus document that can be used by commissioners and service providers in implementing ESD services. Our aim is to promote the use of recommendations derived from research findings to facilitate successful implementation of stroke services nationally and internationally.
Greater Adherence to Secondary Prevention Medications Improves Survival After Stroke or Transient Ischemic Attack: A Linked Registry Study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2021
DOI: 10.1161/STROKEAHA.120.033133
Abstract: Although a target of 80% medication adherence is commonly cited, it is unclear whether greater adherence improves survival after stroke or transient ischemic attack (TIA). We investigated associations between medication adherence during the first year postdischarge, and mortality up to 3 years, to provide evidence-based targets for medication adherence. Retrospective cohort study of 1-year survivors of first-ever stroke or TIA, aged ≥18 years, from the Australian Stroke Clinical Registry (July 2010–June 2014) linked with nationwide prescription refill and mortality data (until August 2017). Adherence to antihypertensive agents, statins, and nonaspirin antithrombotic medications was based on the proportion of days covered from discharge until 1 year. Cox regression with restricted cubic splines was used to investigate nonlinear relationships between medication adherence and all-cause mortality (to 3 years postdischarge). Models were adjusted for age, sex, socioeconomic position, stroke factors, primary care factors, and concomitant medication use. Among 8363 one-year survivors of first-ever stroke or TIA (44% aged ≥75 years, 44% female, 18% TIA), 75% were supplied antihypertensive agents. In patients without intracerebral hemorrhage (N=7446), 84% were supplied statins, and 65% were supplied nonaspirin antithrombotic medications. Median adherence was ≈90% for each medication group. Between 1% and 100% adherence, greater adherence to statins or antihypertensive agents, but not nonaspirin antithrombotic agents, was associated with improved survival. When restricted to linear regions above 60% adherence, each 10% increase in adherence was associated with a reduction in all-cause mortality of 13% for antihypertensive agents (hazard ratio, 0.87 [95% CI, 0.81–0.95]), 13% for statins (hazard ratio, 0.87 [95% CI, 0.80–0.95]), and 15% for nonaspirin antithrombotic agents (hazard ratio, 0.85 [95% CI, 0.79–0.93]). Greater levels of medication adherence after stroke or TIA are associated with improved survival, even among patients with near-perfect adherence. Interventions to improve medication adherence are needed to maximize survival poststroke.
Better outcomes for hospitalized patients with TIA when in stroke units: an observational study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-05-2016
Implementing a Goal-Directed Care Bundle after Acute Intracerebral Haemorrhage: Process Evaluation for the Third INTEnsive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial Study in China
Publisher: S. Karger AG
Date: 20-12-2022
DOI: 10.1159/000520669
Abstract: b i Background: /i /b The third INTEnsive care bundle with blood pressure Reduction in Acute Cerebral Haemorrhage Trial is an ongoing international, multicentre, stepped wedge, cluster-randomized trial to determine the effectiveness of a goal-directed care bundle (early intensive blood pressure [BP] lowering, glycaemic control, treatment of pyrexia, and reversal of anticoagulation), as compared to standard of care, on patient-centred outcomes after acute intracerebral haemorrhage (ICH). An embedded process evaluation aims to identify factors related to the uptake and implementation of the intervention. Herein, we present the process evaluation results for hospital sites in China. b i Methods/Design: /i /b A mixed methods approach, including surveys, focused group discussions and interviews with clinicians, routine monitoring, and recruitment logs were used to collect data across purposively s led hospitals. Medical Research Council guidance and normalization process theory were used as theoretical frameworks for design, data analysis, and synthesis. b i Results: /i /b Twenty quantitative surveys were completed with clinicians, and 26 interviews and 2 focus group discussions were conducted during 2019–2020. The care bundle was generally delivered as planned and acceptable by doctors and nurses, but difficulties were reported in achieving the protocol-defined target levels of BP and glycaemic control. Resistance to implementing the care bundle occurred for patients perceived to be at high risk of adverse effects. Common organizational contextual factors that impeded implementation included delayed processes and limited medication supply, while established background care procedures, expertise, and capacity influenced its integration into routine practice. Areas to facilitate implementation included optimizing workflow within available resources, having a dedicated team, and recognizing the potential benefits of the intervention. b i Conclusions: /i /b Varied established care protocols across sites, different levels of background expertise, and lack of staff capacity impeded the integration of goal-directed care bundle into routine practice for ICH patients in China. Ready identification, and efforts to address, these barriers could facilitate uptake of future guideline-recommended interventions for the management of patients with ICH.
COVID-19 pandemic impact on care for stroke in Australia: emerging evidence from the Australian stroke clinical registry
Publisher: Frontiers Media SA
Date: 26-02-2021
DOI: 10.3389/FNEUR.2021.621495
Abstract: We present information on acute stroke care for the first wave of the COVID-19 pandemic in Australia using data from the Australian Stroke Clinical Registry (AuSCR). The first case of COVID-19 in Australia was recorded in late January 2020 and national restrictions to control the virus commenced in March. To account for seasonal effects of stroke admissions, patient-level data from the registry from January to June 2020 were compared to the same period in 2019 (historical-control) from 61 public hospitals. We compared periods using descriptive statistics and performed interrupted time series analyses. Perceptions of stroke clinicians were obtained from 53/72 (74%) hospitals participating in the AuSCR (80% nurses) via a voluntary, electronic feedback survey. Survey data were summarized to provide contextual information for the registry-based analysis. Data from the registry covered locations that had 91% of Australian COVID-19 cases to the end of June 2020. For the historical-control period, 9,308 episodes of care were compared with the pandemic period (8,992 episodes). Patient characteristics were similar for each cohort (median age: 75 years 56% male ischemic stroke 69%). Treatment in stroke units decreased progressively during the pandemic period (control: 76% pandemic: 70%, p & 0.001). Clinical staff reported fewer resources available for stroke including 10% reporting reduced stroke unit beds. Several time-based metrics were unchanged whereas door-to-needle times were longer during the peak pandemic period (March-April, 2020 82 min, control: 74 min, p = 0.012). Our data emphasize the need to maintain appropriate acute stroke care during times of national emergency such as pandemic management.
Influence of socioeconomic status on functional outcomes after stroke: a systematic review and meta-analysis
Publisher: Cold Spring Harbor Laboratory
Date: 09-10-2023
Subarachnoid haemorrhage occurrence exhibits a temporal pattern – evidence from meta‐analysis
Publisher: Wiley
Date: 09-2002
DOI: 10.1046/J.1468-1331.2002.00455.X
Abstract: The aim of the present meta-analysis was to determine a temporal pattern of occurrence of subarachnoid haemorrhage (SAH). A MEDLINE 1966-2001 and EMBASE (1980-2001) literature search and hand search of relevant references were performed for population-based incidence studies that reported the time of SAH occurrence. Data from all identified relevant studies were combined into a pooled rate ratio (RR), with corresponding 95% confidence intervals (CI) using the Mantel-Haenszel method. Overall, eight population-based studies were included in the analysis. A total of 2533 first-ever cases of SAH were reported in the studies identified. Risk of SAH occurrence was the highest in the period between 6 am and 12 am (RR = 3.19 95% CI 3.03-3.36 early morning as a reference variable) and between 12 p.m. and 6 p.m. (RR = 2.63 95% CI 2.47-2.80), in winter and spring (RR = 1.10 95% CI: 1.02-1.17 and RR = 1.07 95% CI: 1.01-1.13, respectively summer as a reference variable) and on Sunday (RR = 1.22 95% CI 1.09-1.37 Monday as a reference variable). The evidence suggests that occurrence of SAH exhibits a seasonal (winter and spring) peak, diurnal (late morning peak) and daily (Sunday peak) pattern. It is suggested that the occurrence of some major acute vascular events (total ischaemic strokes, intracerebral haemorrhage and myocardial infarction) may be influenced by common triggering factors.
Repeated Measures of Modified Rankin Scale Scores to Assess Functional Recovery From Stroke: AFFINITY Study Findings
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 16-08-2022
Abstract: Function after acute stroke using the modified Rankin Scale (mRS) is usually assessed at a point in time. The analytical implications of serial mRS measurements to evaluate functional recovery over time is not completely understood. We compare repeated‐measures and single‐measure analyses of the mRS from a randomized clinical trial. Serial mRS data from AFFINITY (Assessment of Fluoxetine in Stroke Recovery), a double‐blind placebo randomized clinical trial of fluoxetine following stroke (n=1280) were analyzed to identify demographic and clinical associations with functional recovery (reduction in mRS) over 12 months. Associations were identified using single‐measure (day 365) and repeated‐measures (days 28, 90, 180, and 365) partial proportional odds logistic regression. Ninety‐five percent of participants experienced a reduction in mRS after 12 months. Functional recovery was associated with age at stroke years no prestroke history of diabetes, coronary heart disease, or ischemic stroke prestroke history of depression, a relationship partner, living with others, independence, or paid employment no fluoxetine intervention ischemic stroke (compared with hemorrhagic) stroke treatment in Vietnam (compared with Australia or New Zealand) longer time since current stroke and lower baseline National Institutes of Health Stroke Scale & Patient Health Questionnaire‐9 scores. Direction of associations was largely concordant between single‐measure and repeated‐measures models. Association strength and variance was generally smaller in the repeated‐measures model compared with the single‐measure model. Repeated‐measures may improve trial precision in identifying trial associations and effects. Further repeated‐measures stroke analyses are required to prove methodological value. URL: www.anzctr.org.au Unique identifier: ACTRN12611000774921.
Validation of the simplified modified Rankin scale for stroke trials: Experience from the ENCHANTED alteplase-dose arm
Publisher: SAGE Publications
Date: 22-01-2020
Abstract: The structured, simplified modified Rankin scale questionnaire (smRSq) may increase reliability over the interrogative approach to scoring the modified Rankin scale (mRS) in acute stroke research and practice. During the conduct of the alteplase-dose arm of the international ENhanced Control of Hypertension ANd Thrombolysis StrokE stuDy (ENCHANTED), we had an opportunity to compare each of these approaches to outcome measurement. Baseline demographic data were recorded together with the National Institutes of Health Stroke Scale (NIHSS). Follow-up measures obtained at 90 days included mRS, smRSq, and the 5-Dimension European Quality of life scale (EQ-5D). Agreements between smRSq and mRS were assessed with the Kappa statistic. Multiple logistic regression was used to identify baseline predictors of Day 90 smRSq and mRS scores. Treatment effects, based on Day 90 smRSq/mRS scores, were tested in logistic and ordinal logistic regression models. SmRSq and mRS scores had good agreement (weighted Kappa 0.79, 95% confidence interval (CI) 0.78–0.81), while variables of age, atrial fibrillation, diabetes mellitus, pre-morbid mRS (1 vs. 0), baseline NIHSS scores, and imaging signs of cerebral ischemia, similarly predicted their scores. Odds ratios for death or disability, and ordinal shift, 90-day mRS scores using smRSq were 1.05 (95% CI 0.91–1.20 one-sided P = 0.23 for non-inferiority) and 0.98 (95% CI 0.87–1.11 P = 0.02 for non-inferiority), similar to those using mRS. This study demonstrates the utility of the smRSq in a large, ethnically erse clinical trial population. Scoring of the smRSq shows adequate agreement with the standard mRS, thus confirming it is a reliable, valid, and useful alternative measure of functional status after acute ischemic stroke. URL: www.clinicaltrials.gov . Unique identifier: NCT01422616.
Sleep duration and risk of cardiovascular events: The SAVE study
Publisher: SAGE Publications
Date: 03-02-2020
Abstract: Controversy exists regarding cardiovascular risk in relation to sleep duration. We determined sleep duration and major recurrent cardiovascular event associations in patients with obstructive sleep apnoea and established cardiovascular disease. Secondary analyses of the international, multicenter, Sleep Apnea Cardiovascular Endpoints trial. Sleep duration was estimated from overnight home oximetry (ApneaLink monitor) used for obstructive sleep apnoea diagnosis. Cox proportional hazards models were used to determine associations of categorized sleep duration ( h, 6–8 h (reference), and h) and major cardiovascular outcomes: primary composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and any hospitalization for unstable angina, heart failure, or transient ischemic attack secondary composite of cardiac and cerebral (stroke/transient ischemic attack) events. Oximetry-derived sleep duration estimates were available in 2687 participants (mean 61.2 years, 80.9% males) who experienced a total of 436 cardiovascular events over a mean follow-up of 3.7 years. Compared to the reference category, sleep duration was not associated with risk of the primary composite cardiovascular outcome (adjusted hazard ratio (HR) 1.00, 95% confidence interval 0.76–1.33, and HR 1.22, 95% confidence interval 0.98–1.52, for sleep duration and h, respectively). However, long sleep was associated with increased cerebral events (HR 1.67, 95% confidence interval 1.17–2.39 P = 0.005) and stroke alone (HR 1.79, 95% confidence interval 1.22–2.63 P = 0.003). Long sleep duration is associated with an increased risk of stroke but not cardiac events in obstructive sleep apnoea patients with existing cardiovascular disease. The trial is registered at ClinicalTrials.gov (NCT00738179).
Measuring stroke and transient ischemic attack burden in New Zealand: Protocol for the fifth Auckland Regional Community Stroke Study (ARCOS V)
Publisher: SAGE Publications
Date: 24-10-2019
Abstract: Aim: The goal of this paper is to provide a protocol for conducting a fifth population-based Auckland Regional Community Stroke study (ARCOS V) in New Zealand. Methods and Discussion: In this study, for the first time globally, (1) stroke and TIA burden will be determined using the currently used clinical and tissue-based definition of stroke, in addition to the WHO clinical classifications of stroke used in all previous ARCOS studies, as well as more advanced criteria recently suggested for an “ideal” population-based stroke incidence and outcomes study and (2) age, sex, and ethnic-specific trends in stroke incidence and outcomes will be determined over the last four decades, including changes in the incidence of acute cerebrovascular events over the last decade. Furthermore, information at four time points over a 40-year period will allow the assessment of effects of recent changes such as implementation of the FAST c aign, ambulance pre-notification, and endovascular treatment. This will enable more accurate projections for health service planning and delivery. Conclusion: The methods of this study will provide a foundation for future similar population-based studies in other countries and populations.
Regional Differences in Early BP Management After Acute Ischemic Stroke in the ENCHANTED International Randomized Controlled Trials
Publisher: Frontiers Media SA
Date: 27-08-2021
DOI: 10.3389/FNEUR.2021.687862
Abstract: Background and Aims: Epidemiological studies show significant variations in hypertension management within and between countries. The level of regional variation in early blood pressure (BP) management after acute stroke is uncertain. Methods: Data are from the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED), a partial-factorial, international randomized controlled trial of thrombolysis-eligible acute ischemic stroke (AIS) patients with elevated systolic BP (SBP & mmHg) assigned to intensive (target SBP 130-140 mmHg) vs. guideline-recommended (SBP & mmHg) treatment BP management was compared among four regions: Western countries (Italy/United Kingdom/Spain/Australia), China (mainland), other Asia (Hong Kong/Taiwan/Singapore/Thailand/Vietnam/India), and South America (Chile/Brazil/Colombia). Results: These analyses included 2,196 AIS [38% women, mean age 67 (12) years] patients. Commonly used intravenous BP-lowering agents were labetalol, nitroglycerin, and topical nitrates in Western countries urapidil and sodium nitroprusside in China nicardipine in other Asian countries and sodium nitroprusside and labetalol in South America. Chinese patients were less likely to receive BP-lowering treatment in the first 24 h and be treated with multiple agents although they had smaller magnitude of SBP reduction and lower SBP variability. Conclusion: Regional variations in early BP management in acute stroke translated into differences in early BP control parameters.
Does blood pressure lowering treatment prevents dementia or cognitive decline in patients with cardiovascular and cerebrovascular disease?
Publisher: Elsevier BV
Date: 03-2005
DOI: 10.1016/J.JNS.2004.11.020
Abstract: There is increasing evidence that both hypertension and stroke play important roles in the development of cognitive decline and dementia. Despite five high-quality randomised controlled trials (RCTs) in this area to date, there remains uncertainty about the role of blood pressure lowering therapy in the prevention of cognitive decline and dementia. It appears that lack of definitive results from these trials can be explained on the basis of (a) insufficient power to detect modest treatment effects (b) measurement error in the diagnosis of dementia (c) variations in the treatment effects between different types of antihypertensive agents and (d) bias due to missing data, variation in baseline factors such as levels of blood pressure, and the inclusion of patients with cognitive impairment at entry. Preliminary meta-analysis of RCTs supports the hypothesis that blood pressure lowering may prevent dementia in high-risk patients, that is those with vascular disease. However, a meta-analysis of in idual patient data (IPD) from these, and other relevant trials in patients with vascular disease, would provide much more reliable data. If the hypothesis were confirmed, it would certainly be of considerable importance not only in terms of our understanding of the aetiology of dementia, but also in promoting blood pressure lowering strategies for broader public health good.
Proteinuria and Stroke: A Meta-analysis of Cohort Studies
Publisher: Elsevier BV
Date: 03-2009
DOI: 10.1053/J.AJKD.2008.08.032
Abstract: The associations between decreased kidney function and cardiovascular disease recently have been established. However, there is uncertainty about the consistency between the independent associations of proteinuria as a risk factor across all cardiovascular end points. We undertook a meta-analysis of published cohort studies to provide a reliable estimate of the strength of association between proteinuria and risk of stroke. Meta-analysis of observational cohort studies. General population of participants with diabetes. Studies were excluded if participants had known glomerular disease or had undergone dialysis or transplantation. MEDLINE, EMBASE, and CINAHL databases were searched for studies that reported age- or multivariate-adjusted risk ratio with some estimate of the variance of the association between proteinuria and risk of stroke, without language restriction. Proteinuria or albuminuria. Fatal or nonfatal stroke. Data from 10 published studies involving 140,231 participants and 3,266 strokes were eligible for inclusion. Participants with proteinuria had a 71% greater risk of stroke compared with those without proteinuria (95% confidence interval, 1.39 to 2.10). There was evidence of significant quantitative heterogeneity in the magnitude of the association across studies (I(2) = 60% P for heterogeneity = 0.008), which was partially explained by differences in methods for measuring proteinuria. The risk of stroke remained significant after adjustment for other vascular risk factors. Because in idual patient data were unavailable, we were unable to fully examine the impact of adjustment for known cardiovascular risk factors on the strength of the association between proteinuria and stroke risk. It is possible that the pooled estimate was affected by regression dilution bias. These findings support the independent relationship between proteinuria and stroke. Additional studies are warranted to determine whether interventions to reduce proteinuria are effective at reducing rates of stroke.
A Randomized, Controlled Trial of Quadriceps Resistance Exercise and Vitamin D in Frail Older People: The Frailty Interventions Trial in Elderly Subjects (FITNESS)
Publisher: Wiley
Date: 20-02-2003
DOI: 10.1046/J.1532-5415.2003.51101.X
Abstract: To determine the effectiveness of vitamin D and home-based quadriceps resistance exercise on reducing falls and improving the physical health of frail older people after hospital discharge. Multicenter, randomized, controlled trial with a factorial design. Five hospitals in Auckland, New Zealand, and Sydney, Australia. Two hundred forty-three frail older people. Patients were randomized to receive a single dose of vitamin D (calciferol, 300,000 IU) or placebo tablets and 10 weeks of high-intensity home-based quadriceps resistance exercise or frequency-matched visits. The primary endpoints were physical health according to the short-form health survey at 3 months and falls over 6 months. Physical performance and self-rated function were secondary endpoints. Assessments took place in the participants' homes at 3 and 6 months after randomization and were performed by blinded assessors. There was no effect of either intervention on physical health or falls, but patients in the exercise group were at increased risk of musculoskeletal injury (risk ratio = 3.6, 95% confidence interval = 1.5-8.0). Vitamin D supplementation did not improve physical performance, even in those who were vitamin D deficient (<12 ng/mL) at baseline. Neither vitamin D supplementation nor a home-based program of high-intensity quadriceps resistance exercise improved rehabilitation outcomes in frail older people after hospitalization. There was no effect of vitamin D on physical performance, and the exercises increased the risk of musculoskeletal injury. These findings do not support the routine use of these interventions at these dosages in the rehabilitation of frail older people.
Perindopril-based blood pressure lowering reduces major vascular events in Asian and Western participants with cerebrovascular disease: the PROGRESS trial.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2010
Declining stroke rates in southern Brazil: A positive result of socioeconomic development?
Publisher: BMJ
Date: 16-06-2009
Determinants of physical health in frail older people: the importance of self-efficacy
Publisher: SAGE Publications
Date: 04-2006
DOI: 10.1191/0269215506CR946OA
Abstract: Objective: There is continued uncertainty regarding the strength of association between performance-based and self-report measures of physical functioning, and of their relationship to self-efficacy and health-related quality of life (HRQoL). This study assessed the inter-relationships between such measures, and the predictors of ‘physical’ aspects of HRQoL in frail older patients. Design: We used statistical models to determine the predictors of ‘physical’ HRQoL, according to the physical component summary score and the physical functioning domain of the 36-item short form (SF-36) questionnaire. Setting: Patients were recruited from hospitals in Australia and New Zealand and followed up in their homes. Subjects: Two hundred and forty-three frail older patients. Main measures: Physical functioning was assessed using three performance-based measures (Timed Up and Go Test, gait speed and the Berg Balance Scale) and five self-report measures, including the modified falls self-efficacy scale, at three and six months after registration. Results: A moderate association (r=0.48=0.55) was found between each of the performance-based and self-report measures, including the SF-36 physical component summary score. Multiple linear regression analyses showed that the performance-based measures and falls self-efficacy predicted 33% of the SF-36 physical component summary score. Falls self-efficacy was the single highest predictor of both the SF-36 physical component summary score and SF-36 physical functioning domain. A curvilinear relationship was found between the SF-36 physical functioning domain and two variables: falls self-efficacy and the Berg Balance Scale. Conclusions: Although performance-based and self-report measures provide complementary but distinct measures of physical function, psychosocial factors such as self-efficacy have a strong influence on the HRQoL of frail older people.
Improved survival after stroke: Is admission to hospital the major explanation? Trend analyses of the Auckland Regional Community Stroke studies
Publisher: S. Karger AG
Date: 16-11-2007
DOI: 10.1159/000097054
Abstract: i Background: /i There is uncertainty regarding the impact of changes in stroke care and natural history of stroke in the community. We examined factors responsible for trends in survival after stroke in a series of population-based studies. i Methods: /i We used statistical models to assess temporal trends in 28-day and 1-year case fatality after first-ever stroke cases registered in 3 stroke incidence studies undertaken in Auckland, New Zealand, over uniform 12-month calendar periods in 1981–1982 (n = 1,030), 1991–1992 (1,305) and 2001–2002 (1,423). Cox proportional hazards regression was used to evaluate the significance of pre-defined ‘patient’, ‘disease’ and ‘service/care’ factors on these trends. i Results: /i Overall, there was a 40% decline in 28-day case fatality after stroke over the study periods, from 32% (95% confidence interval, 29–35%) in 1981–1982 to 23% (21–25%) in 1991–1992 and then 19% (17–21%) in 2002–2003. Similar relative declines were seen in 1-year case fatality. In regression models, the trends were still significant after adjusting for patient and disease factors. However, further adjustment for care factors (higher hospital admission and neuroimaging) explained most of the improvement in survival. i Conclusions: /i These data show significant downwards trends in case fatality after stroke in Auckland over 20 years, which can largely be attributed to improved stroke care associated with increases in hospital admission and brain imaging during the acute phase of the illness.
Unruptured intracranial aneurysms in the Familial Intracranial Aneurysm and International Study of Unruptured Intracranial Aneurysms cohorts: Differences in multiplicity and location - Clinical article
Publisher: Journal of Neurosurgery Publishing Group (JNSPG)
Date: 07-2012
Abstract: Familial predisposition is a recognized nonmodifiable risk factor for the formation and rupture of intracranial aneurysms (IAs). However, data regarding the characteristics of familial IAs are limited. The authors sought to describe familial IAs more fully, and to compare their characteristics with a large cohort of nonfamilial IAs. The Familial Intracranial Aneurysm (FIA) study is a multicenter international study with the goal of identifying genetic and other risk factors for formation and rupture of IAs in a highly enriched population. The authors compared the FIA study cohort with the International Study of Unruptured Intracranial Aneurysms (ISUIA) cohort with regard to patient demographic data, IA location, and IA multiplicity. To improve comparability, all patients in the ISUIA who had a family history of IAs or subarachnoid hemorrhage were excluded, as well as all patients in both cohorts who had a ruptured IA prior to study entry. Of 983 patients enrolled in the FIA study with definite or probable IAs, 511 met the inclusion criteria for this analysis. Of the 4059 patients in the ISUIA study, 983 had a previous IA rupture and 657 of the remainder had a positive family history, leaving 2419 in iduals in the analysis. Multiplicity was more common in the FIA patients (35.6% vs 27.9%, p 0.001). The FIA patients had a higher proportion of IAs located in the middle cerebral artery (28.6% vs 24.9%), whereas ISUIA patients had a higher proportion of posterior communicating artery IAs (13.7% vs 8.2%, p = 0.016). Heritable structural vulnerability may account for differences in IA multiplicity and location. Important investigations into the underlying genetic mechanisms of IA formation are ongoing.
Baseline measures and outcome predictions
Publisher: S. Karger AG
Date: 1994
DOI: 10.1159/000110392
Abstract: This paper reviews the methodological issues in the epidemiological study of the outcome from stroke. Data are presented from an unselected series of patients in whom the underlying stroke pathology is clearly defined. Although the natural history varies among the different pathological subtypes of stroke, simple clinical baseline measures of the severity of the neurological deficit (incontinence, loss of consciousness and severity of paresis) and premorbid level of disability and social functioning independently predict disability-free survival by 1 year, and may help direct management and research.
Progress towards optimizing blood pressure control after reperfusion therapy for acute ischemic stroke
Publisher: Wiley
Date: 29-03-2021
DOI: 10.1111/ENE.14808
Frequency of coexistent eye diseases and cognitive impairment or dementia
Publisher: Springer Science and Business Media LLC
Date: 15-03-2023
DOI: 10.1038/S41433-023-02481-4
Abstract: We aim to quantify the co-existence of age-related macular degeneration (AMD), glaucoma, or diabetic retinopathy (DR) and cognitive impairment or dementia. MEDLINE, EMBASE, PsycINFO and CINAHL were searched (to June 2020). Observational studies reporting incidence or prevalence of AMD, glaucoma, or DR in people with cognitive impairment or dementia, and of cognitive impairment or dementia among people with AMD, glaucoma, or DR were included. Fifty-six studies (57 reports) were included but marked by heterogeneities in the diagnostic criteria or definitions of the diseases, study design, and case mix. Few studies reported on the incidence. Evidence was sparse but consistent in in iduals with mild cognitive impairment where 7.7% glaucoma prevalence was observed. Prevalence of AMD and DR among people with cognitive impairment ranged from 3.9% to 9.4% and from 11.4% to 70.1%, respectively. Prevalence of AMD and glaucoma among people with dementia ranged from 1.4 to 53% and from 0.2% to 25.9%, respectively. Prevalence of DR among people with dementia was 11%. Prevalence of cognitive impairment in people with AMD, glaucoma, and DR ranged from 8.4% to 52.4%, 12.3% to 90.2%, and 3.9% to 77.8%, respectively, and prevalence of dementia in people with AMD, glaucoma and DR ranged from 9.9% to 62.6%, 2.5% to 3.3% and was 12.5%, respectively. Frequency of comorbid eye disease and cognitive impairment or dementia varied considerably. While more population-based estimations of the co-existence are needed, interdisciplinary collaboration might be helpful in the management of these conditions to meet healthcare needs of an ageing population. PROSPERO registration: CRD42020189484.
Thrombolysis outcomes according to arterial characteristics of acute ischemic stroke by alteplase dose and blood pressure target
Publisher: SAGE Publications
Date: 24-06-2022
DOI: 10.1177/17474930211025436
Abstract: We explored the influence of low-dose intravenous alteplase and intensive blood pressure lowering on outcomes of acute ischemic stroke according to status/location of vascular obstruction in participants of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). ENCHANTED was a multicenter, quasi-factorial, randomized trial to determine efficacy and safety of low- versus standard-dose intravenous alteplase and intensive- versus guideline-recommended blood pressure lowering in acute ischemic stroke patients. In those who had baseline computed tomography or magnetic resonance imaging angiography, the degree of vascular occlusion was grouped according to being no (NVO), medium (MVO), or large (LVO). Logistic regression models were used to determine 90-day outcomes (modified Rankin scale [mRS] shift [primary], other mRS cut-scores, intracranial hemorrhage, early neurologic deterioration, and recanalization) by vascular obstruction status/site. Heterogeneity in associations for outcomes across subgroups was estimated by adding an interaction term to the models. There were 940 participants: 607 in alteplase arm only, 243 in blood pressure arm only, and 90 assigned to both arms. Compared to the NVO group, functional outcome was worse in LVO (mRS shift, adjusted OR [95% CI] 2.13 [1.56–2.90]) but comparable in MVO (1.34 [0.96–1.88]) groups. There were no differences in associations of alteplase dose or blood pressure lowering and outcomes across NVO/MVO/LVO groups (mRS shift: low versus standard alteplase dose 0.84 [0.54–1.30]/0.48 [0.25–0.91]/0.99 [0.75–2.09], P interaction = 0.28 intensive versus standard blood pressure lowering 1.32 [0.74–2.38]/0.78 [0.31–1.94]/1.24 [0.64–2.41], P interaction = 0.41), except for a borderline significant difference for intensive blood pressure lowering and increased early neurologic deterioration (0.63 [0.14–2.72]/0.17 [0.02–1.47]/2.69 [0.90–8.04], P interaction = 0.05). Functional outcome by dose of alteplase or intensity of blood pressure lowering is not modified by vascular obstruction status/site according to analyses from ENCHANTED, although these results are compromised by low statistical power. Clinical Trial Registration: www.clinicaltrials.gov . Unique identifiers: NCT01422616
Erratum: Unruptured intracranial aneurysms in the Familial Intracranial Aneurysm and International Study of Unruptured Intracranial Aneurysms cohorts: Differences in multiplicity and location. Clinical article (Journal of Neurosurgery (2012) DOI: 10.3171/2012.4.JNS111822)
Publisher: Journal of Neurosurgery Publishing Group (JNSPG)
Date: 07-2012
Disparities between Asian and Non-Asian Thrombolyzed Acute Ischemic Stroke Patients in the Enhanced Control of Hypertension and Thrombolysis Stroke Trial
Publisher: S. Karger AG
Date: 2021
DOI: 10.1159/000516487
Abstract: b i Background and Purpose: /i /b As outcomes for acute ischemic stroke (AIS) vary according to clinical profile and management approaches, we aimed to determine disparities in clinical outcomes between Asian and non-Asian participants of the international, Enhanced Control of Hypertension and Thrombolysis Stroke study (ENCHANTED). b i Methods: /i /b ENCHANTED was a multicenter, prospective, partial-factorial, randomized, open trial of low-dose (0.6 mg/kg) versus standard-dose (0.9 mg/kg) alteplase, and intensive (target systolic blood pressure [SBP] 130–140 mm Hg) or guideline-recommended (& #x3c mm Hg) BP management, in thrombolysis-eligible AIS patients. Logistic regression models were used to examine the associations with outcomes of death or disability (modified Rankin scale [mRS] scores 2–6), major disability (mRS 3–5), death, and intracranial hemorrhage (ICH), with adjustment prognostic factors, alteplase dose, and mean SBP over 1–24 h. b i Results: /i /b Among 4,551 thrombolyzed AIS patients (mean age 66.7 years, 37.8% female), there were 65.4% Asians who were younger, fewer female, and with less atrial fibrillation, hypercholesterolemia, premorbid symptoms, and concomitant antihypertensive, antithrombotic and statin treatment, and more prior stroke, compared to non-Asians. Frequencies of hypertension, coronary artery disease, and diabetes mellitus were comparable between groups. Asian patients were less likely to be admitted to an acute stroke unit and receive early mobilization by a therapist or rehabilitation but more likely to receive intensive care. There were no significant differences between Asians and non-Asians in functional outcome (defined by mRS scores 2–6 or 3–5 adjusted odds ratio [OR] 1.00, 95% confidence interval [CI] 0.85–1.19 [ i /i = 0.958] and OR 0.95, 95% CI 0.80–1.13 [ i /i = 0.572], respectively), or death (OR 1.25, 95% CI 0.95–1.65 i /i = 0.116), despite Asians having greater odds of ICH (OR 1.51, 95% CI 1.23–1.86 i /i = 0.0001) and neurological deterioration within 24 h (OR 1.58, 95% CI 1.18–2.12 i /i = 0.002). b i Conclusions: /i /b Within the context of an international clinical trial of thrombolyzed AIS patients, demography, risk factors, management, and odds of early neurological deterioration and ICH, all differ between Asian and non-Asian participants. However, patterns of functional recovery are similar between these major regional groups.
Frequency, management, and predictors of abnormal mood after stroke: The Auckland Regional Community Stroke (ARCOS) study, 2002 to 2003
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2006
DOI: 10.1161/01.STR.0000231387.58943.1F
Abstract: Background and Purpose— Mood disorders are an important consequence of stroke. We aimed to identify significant, clinically useful predictors of abnormal mood after stroke. Methods— The Auckland Regional Community Stroke (ARCOS) study was a prospective population-based stroke incidence study conducted in Auckland, New Zealand, over a 12-month period from 2002 to 2003. All patients were followed up 6 months after stroke onset and abnormal mood was assessed using the 28-item General Health Questionnaire (GHQ-28) administered as part of a structured telephone interview. Multivariate stepwise logistic regression was used to develop a predictive model for “caseness” (score of ≥5 on the GHQ-28) based on several premorbid patient and clinical variables assessed at baseline and 28 days of follow up. Results— Of patients available at 6 months (n=1172), complete data on mood was available from 739 (60%) patients and 27% (95% confidence interval, 24 to 30%) were defined as cases. Key baseline predictors of abnormal mood were disability and history of depression after adjustment for sex, age, and comorbidity, but the model failed to predict a large amount of the variation in caseness ( C statistic 0.587). Conclusion— This study emphasizes the complex nature of mood disturbance after stroke and that multiple factors are likely to contribute to mood disorders. A simple, clinically applicable, predictive model in stroke care appears difficult to develop.
Very long-term outcome after stroke in Auckland, New Zealand
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2004
DOI: 10.1161/01.STR.0000133130.20322.9F
Abstract: Background and Purpose— Limited information exists on the long-term outcome from stroke. We aimed to determine survival and health status at 21-year follow-up of patients who participated in a population-based stroke incidence study undertaken in Auckland, New Zealand. Methods— During 12 months beginning March 1, 1981, half of all residents of Auckland with acute first-ever or recurrent stroke (n=680) were assessed and followed up prospectively during the next 2 decades. In 2002, their vital status and health-related quality of life (HRQoL) using the 36-item short-form questionnaire (SF-36) were determined by telephone interviews. Kaplan–Meier survival probabilities for the stroke cohort were compared with life table estimates for the New Zealand population. The SF-36 profile of 21-year stroke survivors was compared with a standardized New Zealand population. Results— Overall, 626 of the original cohort had died and 4 were lost to follow-up, leaving 50 (7%) in iduals (57% male mean age 70 years) available in 2002, of whom 12% were residents of an institutional care facility and 19% required help with everyday activities. The stroke cohort had nearly twice the mortality rate of the New Zealand population, but the SF-36 profile of very long-term stroke survivors was broadly similar to the general population. Conclusions— Because stroke is generally a disease of older people and has a high case fatality, it is not surprising that in 10 people survive 2 decades after onset. However, of those who do, their HRQoL profile suggests that they meld relatively successfully within the general population, despite ongoing disability and a higher mortality risk.
INTEnsive care bundle with blood pressure reduction in acute cerebral hemorrhage trial (INTERACT3): study protocol for a pragmatic stepped-wedge cluster-randomized controlled trial
Publisher: Springer Science and Business Media LLC
Date: 12-2021
DOI: 10.1186/S13063-021-05881-7
Abstract: Early intensive blood pressure (BP) lowering remains the most promising treatment for acute intracerebral hemorrhage (ICH), despite discordant results between clinical trials and potential variation in the treatment effects by approach to control BP. As the third in a series of clinical trials on this topic, the INTEnsive care bundle with blood pressure Reduction in Acute Cerebral hemorrhage Trial (INTERACT3) aims to determine the effectiveness of a goal-directed care bundle protocol of early physiological control (intensive BP lowering, glycemic control, and pyrexia treatment) and reversal of anticoagulation, in acute ICH. INTERACT3 is a pragmatic, international, multicenter, stepped-wedge (4 phases/3 steps), cluster-randomized controlled trial to determine the effectiveness of a multifaceted care package in adult (age ≥ 18 years) patients (target 8360) with acute ICH ( 6 h of onset) recruited from 110 hospitals (average of 19 consecutive patients per phase) in low- and middle-income countries. After a control phase, each hospital implements the intervention (intensive BP lowering, target systolic 140 mmHg glucose control, target 6.1–7.8 mmol/L and 7.8–10.0 mmol/L in those without and with diabetes mellitus, respectively anti-pyrexia treatment to target body temperature ≤ 37.5 °C and reversal of anticoagulation, target international normalized ratio 1.5 within 1 h). Information will be obtained on demographic and baseline clinical characteristics, in-hospital management, and 7-day outcomes. Central trained blinded assessors will conduct telephone interviews to assess physical function and health-related quality of life at 6 months. The primary outcome is the modified Rankin scale (mRS) at 6 months analyzed using ordinal logistic regression. The s le size of 8360 subjects provides 90% power ( α = 0.05) to detect a 5.6% absolute improvement (shift) in the primary outcome of the intervention versus control standard care, with various assumptions. As the largest clinical trial in acute ICH, INTERACT3 is on schedule to provide an assessment of the effectiveness of a widely applicable goal-directed care bundle for a serious condition in which a clearly proven treatment has yet to be established. ClinicalTrials.gov NCT03209258. Registered on 1 July 2017. Chinese Trial Registry ChiCTR-IOC-17011787. Registered on 28 June 2017
Gender Equity in Leadership and Conferences of the Stroke Society of Australasia
Publisher: S. Karger AG
Date: 15-07-2022
DOI: 10.1159/000517453
Abstract: b i Introduction and Aim: /i /b Internationally, women are underrepresented as leaders in major scientific organizations and conferences. We aimed to determine gender differences in leadership roles and annual scientific conferences of the Stroke Society of Australasia (SSA). b i Methods: /i /b In a retrospective review of SSA data (2014–2019), committee members were obtained through the SSA Web site, and moderators, speakers, and award recipients were identified from SSA annual scientific conference programs. Gender was determined by name inspection and Web search. Absolute numbers and proportions of women and men were recorded for all roles examined, overall and per year. Associations between representation of women in conferences and percentage of women in speaking roles were tested using multinomial regression. b i Results: /i /b Presidential leadership of the SSA was held by men in 2014–2016 and 2019 and women in 2017–2018. SSA committee membership was predominantly women (55%), being lowest (47%) in 2014 and 2019 and highest (65%) in 2017. There was a wide gender variation at scientific conferences, with 41% of keynote speakers being women overall, from 20% in 2016 to 75% in 2015. From 2014 to 2019, 55% of all speakers were women, ranging from 32% (in 2016) to 71% (in 2015). A higher percentage of women as speakers or moderators was associated with a program committee with over a third of its members composed of women ( i /i ≤ 0.044). b i Conclusions: /i /b Representation of women varied from 2014 to 2019 in the SSA organization and its conferences, although men are more often elected president in the organization and women are less often keynote speakers. When more women were included in the program committee, the representation of women as speakers increased.
Carotid endarterectomy for symptomatic, but Haemodynamically Insignificant carotid stenosis
Publisher: Elsevier BV
Date: 10-2010
DOI: 10.1016/J.EJVS.2010.07.003
Abstract: Carotid endarterectomy (CEA) guidelines in symptomatic carotid stenosis are based on NASCET and ECST criteria with 70% or greater carotid stenosis as estimated from a catheter angiogram the major indication. This has several problems: (1) lack of reliable correlation between non-invasive imaging and catheter angiography, which has been largely superseded by non-invasive imaging in investigating carotid stenosis (2) errors inherent in estimating the degree of stenosis from catheter angiography (3) disregard for the fact that stroke risk also depends on plaque stability, and number of ischaemic events. A retrospective review of ischaemic events, imaging results, operative findings, surgical complications and stroke-free follow-up in 31 patients presenting over a 23 year period with TIA/stroke (symptoms lasting > 24 h and/or imaging evidence of infarction) who had 70% or less carotid stenosis (on non-invasive imaging), but nonetheless underwent CEA. Nineteen patients had small strokes, 7 had TIAs and 5 had ocular events 28 patients had features of unstable plaque on imaging 19 patients experienced multiple events before CEA. All had haemorrhagic, ruptured plaque at CEA. One patient suffered an intra-operative stroke, only 1 patient suffered a further stroke/TIA (mean follow-up 4.2 years). To predict the likelihood of major stroke in symptomatic carotid stenosis and the benefit of CEA, plaque stability and the number of ischaemic events might be as important as an estimate of the degree of stenosis.
Associations of an Abnormal Physiological Score With Outcomes in Acute Intracerebral Hemorrhage
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2021
DOI: 10.1161/STROKEAHA.120.030435
Abstract: We determined associations of physiological abnormalities (systolic blood pressure, glucose, and body temperature) and warfarin use with outcomes in spontaneous intracerebral hemorrhage. Post hoc analyses of INTERACT2 (Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial) comparing systolic blood pressure control ( versus mm Hg) in 2839 hypertensive patients with intracerebral hemorrhage (onset hours). Multivariable logistic regression defined associations of baseline scores assigned as 0 to 6 per 10 mm Hg systolic blood pressure increase (range, 150–220 mm Hg) and 0 or 1 for serum glucose (≤6.5 versus .5 mmol/L), body temperature (≤37.5 °C versus .5 °C), and warfarin use (no versus yes) and death or major disability (modified Rankin Scale scores 3–6 at 90 days). Baseline score distribution was 0 (7.7%), 1 (15.6%), 2 (19.0%), 3 (19.1%), 4 (15.2%), 5 (11.6%), 6 (8.9%), and 7 (2.9%). After adjustment for baseline neurological severity and potential confounders, significant linear associations were evident for increasing (per point) score and death or major disability (odds ratio, 1.12 [95% CI, 1.07–1.17]), death (odds ratio, 1.15 [95% CI, 1.07–1.23]), and major disability (odds ratio, 1.10 [95% CI, 1.05–1.15]). Combination of abnormal physiological parameters and warfarin use is associated with poor outcomes in intracerebral hemorrhage. Effects of their early control is under investigation in INTERACT3 (Intensive Care Bundle With Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial). URL: www.clinicaltrials.gov . Unique identifier: NCT00716079.
Frequency of post-stroke pneumonia: Systematic review and meta-analysis of observational studies
Publisher: SAGE Publications
Date: 22-10-2018
Abstract: Post-stroke pneumonia and other infectious complications are serious conditions whose frequency varies widely across studies. We conducted a systematic review to estimate the frequency of post-stroke pneumonia and other types of major infection. MEDLINE, EMBASE, CINAHL, and PsycINFO databases were searched for prospective studies with consecutive recruitment of stroke patients. The primary outcome was post-stroke pneumonia. Secondary outcomes were any infection and urinary tract infection. Quality assessment was done using Newcastle Ottawa scale. Heterogeneity of estimates across study populations was calculated using Cochran's Q (heterogeneity χ 2 ) and I 2 statistics. A total of 47 studies (139,432 patients) with 48 s le populations were eligible for inclusion. Mean age of patients was 68.3 years and their mean National Institute of Health Stroke Scale score was 8.2. The pooled frequency of post-stroke pneumonia was 12.3% (95% confidence interval [CI] 11%–13.6% I 2 = 98%). The pooled frequency from 2011 to 2017 was 13.5% (95% CI 11.8%–15.3% I 2 = 98%) and comparable with earlier periods (P interaction = 0.31). The pooled frequency in studies in stroke units was 8% (95% CI 7.1%–9% I 2 = 78%) and significantly lower than other locations (P interaction = 0.001). The pooled frequency of post-stroke infection was 21% (95% CI 13%–29.3% I 2 = 99%) and of post-stroke urinary tract infection was 7.9% (95% CI 6.7%–9.3% I 2 = 96%). Approximately 1 in 10 stroke patients experience pneumonia during the acute period of hospital care. The frequency of post-stroke pneumonia has remained stable in recent decades but is lower in patients receiving stroke unit care compared to management in other ward settings.
The Perindopril Protection Against Recurrent Stroke Study (PROGRESS): Clinical implications for older patients with cerebrovascular disease
Publisher: Springer Science and Business Media LLC
Date: 2003
DOI: 10.2165/00002512-200320040-00001
Abstract: Blood pressure levels are strongly predictive of the risks of first-ever and recurrent stroke. The benefits of blood pressure-lowering therapy for the prevention of fatal and non-fatal stroke in middle-aged in iduals are well established. However, until recently, there has been uncertainty about the consistency of such benefits across different patient groups and in particular, for older people and in those with a history of stroke. This paper discusses the evidence surrounding the effectiveness of blood pressure-lowering therapy, specifically in older patients with a history of stroke, with particular attention paid to the results from the Perindopril Protection Against Recurrent Stroke Study (PROGRESS). PROGRESS was a randomised, double-blind, placebo-controlled trial of 6105 in iduals with a history of cerebrovascular disease recruited from 172 hospital outpatient clinics in ten countries. Participants (mean age 64 years range 26-91 years) were randomly assigned to receive active treatment with an ACE inhibitor-based blood pressure-lowering regimen (perindopril) with or without addition of the diuretic indapamide, or matched placebo. At the end of follow up (mean of 4 years), active treatment reduced the incidence of total stroke by 28% (95% CI 17-38%) and the rate of major vascular events by 26% (95% CI 16-34%). Importantly, benefits of treatment were consistent across key patient subgroups, including those with and without hypertension, patients who were Asian and non-Asian, and for both ischaemic and haemorrhagic strokes subtypes. Current evidence is now strong for clinicians to consider blood pressure-lowering therapy as pivotal in the prevention of stroke, especially in patients with a known history of cerebrovascular disease (and vascular disease, in general), irrespective of blood pressure levels, as soon as patients are clinically stable after an acute stroke or other vascular event. Additional age-specific analyses of the PROGRESS data, together with those from other completed trials, will provide more reliable information about the size of the benefits of blood pressure-lowering therapy, specifically for different age groups, and particularly in the oldest old (those aged >80 years). In the meantime though, an ACE inhibitor plus diuretic treatment regimen that maximises the degree of blood pressure reduction has a good safety profile and is an effective treatment that should be considered in all patients with stroke, including the elderly.
Frequency and predictors of psychological distress after a diagnosis of epilepsy: A community-based study
Publisher: Elsevier BV
Date: 10-2017
DOI: 10.1016/J.YEBEH.2017.07.044
Abstract: The objective of the study was to determine the frequency and predictors of psychological distress after a diagnosis of epilepsy. The Sydney Epilepsy Incidence Study to Measure Illness Consequences (SEISMIC) was a prospective, multicenter, community-based study of people of all ages with newly diagnosed epilepsy in Sydney, Australia. Analyses involved multivariate logistic regression and multinomial logit regression to identify predictors of psychological distress, assessed using the Hospital Anxiety and Depression Scale (HADS) and the Strengths and Difficulties Questionnaire (SDQ), as part of structured interviews. Psychological distress occurred in 33% (95% confidence interval [CI] 26 to 40%) and 24% (95% CI 18 to 31%) of 180 adults at baseline and 12months, respectively, and 23% (95% CI 14 to 33%) of 77 children at both time points. Thirty adults and 7 children had distress at baseline who recovered at 12months, while 15 adults and 7 children had new onset of distress during this period. History of psychiatric or behavioral disorder (for adults, odds ratio [OR] 6.82, 95% CI 3.08 to 15.10 for children, OR 28.85, 95% CI 2.88 to 288.60) and higher psychosocial disability (adults, OR 1.17, 95% CI 1.07 to 1.27) or lower family functioning (children, OR 1.80, 95% CI 1.08 to 3.02) were associated with psychological distress (C statistics 0.80 and 0.78). Psychological distress is common and fluctuates in frequency after a diagnosis of epilepsy. Those with premorbid psychological, psychosocial, and family problems are at high risk of this adverse outcome.
Better outcomes for hospitalized patients with TIA when in stroke units: An observational studyAuthor Response
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 17-10-2016
The authors reply
Publisher: Massachusetts Medical Society
Date: 08-12-2016
DOI: 10.1056/NEJMC1613219
Prehospital Transdermal Glyceryl Trinitrate for Ultra-Acute Intracerebral Hemorrhage
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2019
DOI: 10.1161/STROKEAHA.119.026389
Abstract: Pilot trials suggest that glyceryl trinitrate (GTN nitroglycerin) may improve outcome when administered early after stroke onset. We undertook a multicentre, paramedic-delivered, ambulance-based, prospective randomized, sham-controlled, blinded-end point trial in adults with presumed stroke within 4 hours of ictus. Participants received transdermal GTN (5 mg) or a sham dressing (1:1) in the ambulance and then daily for three days in hospital. The primary outcome was the 7-level modified Rankin Scale at 90 days assessed by central telephone treatment-blinded follow-up. This prespecified subgroup analysis focuses on participants with an intracerebral hemorrhage as their index event. Analyses are intention-to-treat. Of 1149 participants with presumed stroke, 145 (13% GTN, 74 sham, 71) had an intracerebral hemorrhage: time from onset to randomization median, 74 minutes (interquartile range, 45–110). By admission to hospital, blood pressure tended to be lower with GTN as compared with sham: mean, 4.4/3.5 mm Hg. The modified Rankin Scale score at 90 days was nonsignificantly higher in the GTN group: adjusted common odds ratio for poor outcome, 1.87 (95% CI, 0.98–3.57). A prespecified global analysis of 5 clinical outcomes (dependency, disability, cognition, quality of life, and mood) was worse with GTN Mann-Whitney difference, 0.18 (95% CI, 0.01–0.35 Wei-Lachin test). GTN was associated with larger hematoma and growth, and more mass effect and midline shift on neuroimaging, and altered use of hospital resources. Death in hospital but not at day 90 was increased with GTN. There were no significant between-group differences in serious adverse events. Prehospital treatment with GTN worsened outcomes in patients with intracerebral hemorrhage. Since these results could relate to the play of chance, confounding, or a true effect of GTN, further randomized evidence on the use of vasodilators in ultra-acute intracerebral hemorrhage is needed. URL: www.controlled-trials.com . Unique identifier: ISRCTN26986053.
Implementation of Clinical Guidelines for Secondary Prevention of Stroke
Publisher: SAGE Publications
Date: 14-05-2015
DOI: 10.1111/IJS.12447
Sex Differences in Causes of Death After Stroke: Evidence from a National, Prospective Registry
Publisher: Mary Ann Liebert Inc
Date: 03-2021
Low Prognostic Value of Novel Nocturnal Metrics in Patients With OSA and High Cardiovascular Event Risk: Post Hoc Analyses of the SAVE Study.
Publisher: Elsevier BV
Date: 12-2020
Effect of acetylation/deacetylation on enzymatic hydrolysis of corn stalk
Publisher: Elsevier BV
Date: 12-2014
Acute intracerebral haemorrhage: Grounds for optimism in management
Publisher: Elsevier BV
Date: 12-2012
DOI: 10.1016/J.JOCN.2012.05.018
Abstract: Spontaneous intracerebral haemorrhage (ICH) is one of the most devastating types of stroke, which has considerable disease burden in "non-white" ethnic groups where the population-attributable risks of elevated blood pressure are very high. Since the treatment of ICH remains largely supportive and expectant, nihilism and the early withdrawal of active therapy influence management decisions in clinical practice. However, approaches to management are now better defined on the basis of evidence that both survival and speed (and degree) of recovery are critically dependent on the location, size, and degree of expansion and extension into the intraventricular system of the haematoma of the ICH. Although no medical treatment has been shown to improve outcome in ICH, several promising avenues have emerged that include haemostatic therapy and intensive control of elevated blood pressure. Conversely, there is continued controversy over the role of evacuation of the haematoma of ICH via open craniotomy. Despite being an established practice for several decades, and having undergone evaluation in multiple randomised trials, there is uncertainty over which patients have the most to gain from an intervention with clear procedural risk. Minimally invasive surgery via local anaesthetic applied drill-puncture of the cranium and infusion of a thrombolytic agent is an attractive option for patients requiring critical management of the haematoma, not just in low resource settings but arguably also in specialist centres of western countries. With several ongoing clinical trials nearing completion, these treatments could enter routine practice within the next few years, further justifying the urgency of "time is brain" and that active management within well-organized, comprehensive acute stroke care units includes patients with ICH.
Severe Cerebral White Matter Hyperintensities Predict Severe Cognitive Decline in Patients With Cerebrovascular Disease History
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2009
DOI: 10.1161/STROKEAHA.108.540633
Abstract: Background and Purpose— Cerebral white matter hyperintensities (WMHs) are believed to be the consequence of small vessel disease, and it is uncertain whether their extent predicts the risk of dementia in patients with vascular disease history. Method— Brain MRI was performed in 226 participants of the PROGRESS study. WMH severity was assessed using a visual rating scale. During follow-up, patients were classified for incident severe cognitive deterioration (including dementia) using standard criteria. Results— Over 4-year follow-up, the incidence of severe cognitive deterioration ranged from 1.1 to 9.1 per 100 person-years in patients with respectively no or severe WMHs at baseline. In multivariable analysis, incident severe cognitive deterioration was associated with baseline severe WMHs (odds ratio=7.7, P .005). Conclusion— Higher WMH load is a strong predictor of dementia and cognitive decline in patients with cerebrovascular disease history.
Prolonged hypotension following elective stenting of an internal carotid artery stenosis.
Publisher: BMJ
Date: 09-01-2014
Prior events predict cerebrovascular and coronary outcomes in the PROGRESS trial.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2006
DOI: 10.1161/01.STR.0000221212.36860.C9
Abstract: Background and Purpose— The relationship between baseline and recurrent vascular events may be important in the targeting of secondary prevention strategies. We examined the relationship between initial event and various types of further vascular outcomes and associated effects of blood pressure (BP)–lowering. Methods— Subsidiary analyses of the Perindopril Protection Against Recurrent Stroke Study (PROGRESS) trial, a randomized, placebo-controlled trial that established the benefits of BP–lowering in 6105 patients (mean age 64 years, 30% female) with cerebrovascular disease, randomly assigned to either active treatment (perindopril for all, plus indapamide in those with neither an indication for, nor a contraindication to, a diuretic) or placebo(s). Results— Stroke subtypes and coronary events were associated with 1.5- to 6.6-fold greater risk of recurrence of the same event (hazard ratios, 1.51 to 6.64 P =0.1 for large artery infarction, P .0001 for other events). However, 46% to 92% of further vascular outcomes were not of the same type. Active treatment produced comparable reductions in the risk of vascular outcomes among patients with a broad range of vascular events at entry (relative risk reduction, 25% P .0001 for ischemic stroke 42%, P =0.0006 for hemorrhagic stroke 17%, P =0.3 for coronary events P homogeneity=0.4). Conclusions— Patients with previous vascular events are at high risk of recurrences of the same event. However, because they are also at risk of other vascular outcomes, a broad range of secondary prevention strategies is necessary for their treatment. BP–lowering is likely to be one of the most effective and generalizable strategies across a variety of major vascular events including stroke and myocardial infarction.
La seconde phase d’une étude randomisée, multicentrique évaluant en ouvert l’effet de la réduction intensive de la pression artérielle dans l’hémorragie cérébrale (INTERACT2) : protocole et caractéris
Publisher: Elsevier BV
Date: 04-2012
DOI: 10.1016/J.NEUROL.2011.08.010
Abstract: The INTERACT pilot study demonstrated the feasibility of the protocol, safety of early intensive blood pressure (BP) lowering, and effects on hematoma expansion within 6hours of onset of intracerebral hemorrhage (ICH). This article describes the design of the second, main phase, INTERACT2. INTERACT2 aims to compare the effects of a management strategy of early intensive BP lowering with a more conservative guideline-based BP management policy in patients with acute ICH. This article also compares the baseline characteristics of the patients included in France with the baseline characteristics of the patients included in the pilot study INTERACT1. INTERACT2 is an international, prospective, multicentre, open, assessor-blinded outcome (PROBE), randomised, controlled trial. Patients with a systolic BP greater than 150mmHg are centrally randomised to either to an intensive BP lowering treatment (Systolic BP≤140mmHg within 1hour) or to a conservative treatment strategy (target systolic BP of 180mmHg). A projected 2800 subjects are to be enrolled from approximately 140 centres worldwide to provide 90% power (α 0.05) to detect a beneficial effect of early treatment on the primary outcome. The primary outcome is the combined endpoint of death and dependency according to the modified Rankin Scale (mRS) at 90 days. The key secondary outcome is the primary endpoint in those patients treated within 4hours of ICH. Other predefined secondary outcomes are the separate components of the primary endpoint, grades of physical function on the mRS, health-related quality of life on the EuroQoL, recurrent stroke and other vascular events, days of hospitalisation, requirement for permanent residential care, and unexpected serious adverse events. The study is registered under NCT00716079, ISRCTN73916115, and ACTRN12608000362392. As of early July, 152 patients have been included in France. When compared with the patients randomised in the INTERACT1 pilot study, these patients are older, less likely to have had a previous ICH, more often on antiplatelet or warfarin therapy, have a lower diastolic BP, arere more severe clinically (higher NIHSS) and experience their first ICH.
Determinants of the high admission blood pressure in mild-to-moderate acute intracerebral hemorrhage
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2019
Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study
Publisher: Wiley
Date: 04-1995
DOI: 10.1111/J.1600-0447.1995.TB09778.X
Abstract: Evaluation of the relative efficacy of three screening instruments for depression and anxiety in a group of stroke patients was undertaken as part of the Perth community stroke study. Data are presented on the sensitivity and specificity of the Hospital Anxiety and Depression Scale (HAPS), the Geriatric Depression Scale and the General Health Questionnaire (GHQ) (28-item version) in screening patients 4 months after stroke for depressive and anxiety disorders diagnosed according to DSM-III criteria. The GHQ-28 and GDS but not the HADS depression, were shown to be satisfactory screening instruments for depression, with the GHQ-28 having an overall superiority. The performance of all 3 scales for screening post-stroke anxiety disorders was less satisfactory. The HADS anxiety had the best level of sensitivity, but the specificity and positive predictive values were low and the misclassification rate high.
Reductions in the risks of recurrent stroke in patients with and without diabetes: The PROGRESS Trial
Publisher: Informa UK Limited
Date: 2004
DOI: 10.1080/08037050410029605
Abstract: Analyses of the risks of stroke were conducted for subjects with and without diabetes, participating in a randomized, double-blind, placebo-controlled trial of a perindopril-based blood pressure lowering regimen in 6105 people with prior stroke or transient ischaemic attack (TIA), followed for a median of 3.9 years. Seven hundred and sixty-one patients had diabetes at baseline. Diabetes increased the risk of recurrent stroke by 35% (95% CI 10-65%) principally through an effect on ischaemic stroke (1.53, 95% CI 1.23-1.90). Active treatment reduced blood pressure by 9.5/4.6 mmHg in patients with diabetes and by 8.9/3.9 mmHg in patients without diabetes. The proportional risk reductions achieved for stroke in patients with diabetes, 38% (95% CI 8-58%), and patients without diabetes, 28% (95% CI 16-39%), were not significantly different (p homogeneity = 0.5). The absolute reduction in the risk of recurrent stroke in the patients with diabetes was equivalent to one stroke avoided among every 16 (95% CI 9-111) patients treated for 5 years. Diabetes is an important risk factor for stroke in patients with established cerebrovascular disease. Treatment with the ACE inhibitor perindopril with discretionary use of the diuretic indapamide produced reductions in the risk of recurrent stroke in patients with diabetes that were at least as great as those achieved in patients without diabetes.
Systolic Blood Pressure Time in Target Range and Cognitive Outcomes: Insights From the SPRINT MIND Trial
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2023
DOI: 10.1161/HYPERTENSIONAHA.122.20711
Abstract: The prognostic value of systolic blood pressure (SBP) time in target range (TTR) on cognitive outcomes among adults with hypertension remains unclear. We performed secondary analysis of SPRINT MIND (Systolic Blood Pressure Intervention Trial Memory and Cognition in Decreased Hypertension), which compared intensive ( mm Hg) versus standard ( mm Hg) SBP intervention in hypertensive in iduals. TTR was calculated from baseline to month 3 using 110 to 130 mm Hg and 120 to 140 mm Hg as target range for the intensive and standard groups, respectively. Cognitive outcomes included probable dementia, mild cognitive impairment, and the composite of probable dementia or mild cognitive impairment. Cox regression models were used to evaluate the relationship between SBP-TTR and cognitive outcomes. A total of 8298 patients were included. Participants with higher TTR were younger and less likely to be women or to have a history of cardiovascular disease. After adjustment of baseline demographics, medical history, and mean SBP, a 1-SD (31.5%) increase in TTR was independently associated with a 14% lower risk of probable dementia (hazard ratio, 0.86 [95% CI, 0.76–0.98] P =0.023). Sensitivity analysis showed consistent results when combining target range as 110 to 140 mm Hg. However, there was no significant association between SBP-TTR and mild cognitive impairment. In this post hoc analysis of SPRINT MIND, SBP-TTR was an independent predictor of probable dementia beyond mean SBP. Maintaining SBP within 110 to 140 mm Hg over time may be beneficial for dementia prevention. URL: www.clinicaltrials.gov Unique identifier: NCT01206062.
Telmisartan in high-risk patients intolerant of ACE inhibitors - Authors' reply
Publisher: Elsevier BV
Date: 02-2009
Active and passive smoking and the risk of subarachnoid hemorrhage - An international population-based case-control study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2004
DOI: 10.1161/01.STR.0000115751.45473.48
Abstract: Background and Purpose— This study was undertaken to better clarify the risks associated with cigarette smoking and subarachnoid hemorrhage (SAH). Methods— The study included 432 incident cases of SAH frequency matched to 473 community SAH-free controls to determine dose-dependent associations of active and passive smoking (at home) and smoking cessation with SAH. Results— Compared with never smokers not exposed to passive smoking, the adjusted odds ratio for SAH among current smokers was 5.0 (95% confidence interval [CI], 3.1 to 8.1) for past smokers, 1.2 (95% CI, 0.8 to 2.0) and for passive smokers, 0.9 (95% CI, 0.6 to 1.5). Current and lifetime exposures showed a clear dose-dependent effect, and risks appeared more prominent in women and for aneurysmal SAH. Approximately 1 in 3 cases of SAH could be attributed to current smoking, but risks decline quickly after smoking cessation, even among heavy smokers. Conclusions— A strong positive association was found between cigarette smoking and SAH, especially for aneurysmal SAH and women, which is virtually eliminated within a few years of smoking cessation. Large opportunities exist for preventing SAH through smoking avoidance and cessation programs.
Genome Screen to Detect Linkage to Intracranial Aneurysm Susceptibility Genes
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2008
DOI: 10.1161/STROKEAHA.107.502930
Abstract: Background and Purpose— Evidence supports a substantial genetic contribution to the risk of intracranial aneurysm (IA). The purpose of this study was to identify chromosomal regions likely to harbor genes that contribute to the risk of IA. Methods— Multiplex families having at least 2 in iduals with “definite” or “probable” IA were ascertained through an international consortium. First-degree relatives of in iduals with IA who were at increased risk of an IA because of a history of hypertension or present smoking were offered cerebral magnetic resonance angiography. A genome screen was completed using the Illumina 6K SNP system, and the resulting data from 192 families, containing 1155 genotyped in iduals, were analyzed. Narrow and broad disease definitions were used when testing for linkage using multipoint model-independent methods. Ordered subset analysis was performed to test for a gene×smoking (pack-years) interaction. Results— The greatest evidence of linkage was found on chromosomes 4 (LOD=2.5 156 cM), 7 (LOD=1.7 183 cM), 8 (LOD=1.9 70 cM), and 12 (LOD=1.6 102 cM) using the broad disease definition. Using the average pack-years for the affected in iduals in each family, the genes on chromosomes 4 (LOD=3.5 P =0.03), 7 (LOD=4.1 P =0.01) and 12 (LOD=3.6 P =0.02) all appear to be modulated by the degree of smoking in the affected members of the family. On chromosome 8, inclusion of smoking as a covariate did not significantly strengthen the linkage evidence, suggesting no interaction between the loci in this region and smoking. Conclusions— We have detected possible evidence of linkage to 4 chromosomal regions. There is potential evidence for a gene×smoking interaction with 3 of the loci.
Organizational update Asia pacific stroke organization
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2016
Incidence and outcomes for stroke in Ulaanbaatar, Mongolia, during 2019–21: a prospective population-based study
Publisher: Elsevier BV
Date: 06-2023
Statistical analysis plan for pooled individual patient data from two landmark randomized trials (INTERACT2 and ATACH-II) of intensive blood pressure lowering treatment in acute intracerebral hemorrhage
Publisher: SAGE Publications
Date: 12-11-2018
Abstract: There is persistent uncertainty over the benefits of early intensive systolic blood pressure lowering in acute intracerebral hemorrhage. In particular, over the timing, target, and intensity of systolic blood pressure control for optimum balance of potential benefits (i.e. functional recovery) and risks (e.g. cerebral ischemia). To determine associations of early systolic blood pressure lowering parameters and outcomes in patients with a hypertensive response in acute intracerebral hemorrhage. Secondary aims are to identify the modifying effects of patient characteristics and an optimal systolic blood pressure lowering profile. In idual participant data pooled analyses of two large, multicenter, randomized controlled trials specifically undertaken to assess the effects of early intensive systolic blood pressure reduction on clinical outcomes in acute intracerebral hemorrhage: the Intensive Blood Pressure in Acute Intracerebral Hemorrhage Trial (INTERACT2) and the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH-II) trial. Combined data will include baseline characteristics systolic blood pressure in the first 24 h process of care measures and key efficacy and safety outcomes. The primary outcome is functional recovery, defined by an ordinal distribution of scores on the modified Rankin scale at 90 days post-randomization. Secondary outcomes include various standard binary cut-points for disability-free survival on the modified Rankin scale, and health-related quality of life at 90 days. Safety outcomes include symptomatic hypotension requiring corrective therapy and early neurologic deterioration within 24 h, and deaths, any serious adverse event, and cardiac and renal serious adverse events, within 90 days. A pre-determined protocol was developed to facilitate successful collaboration and reduce analysis bias arising from prior knowledge of the findings. URL: www.clinicaltrials.gov . Unique identifiers for INTERACT2 (NCT00716079) and ATACH-II (NCT01176565).
Stroke Epidemiology in an Australian Rural Cohort (SEARCH)
Publisher: SAGE Publications
Date: 30-09-2017
Abstract: Stroke rates in Australia and New Zealand have been declining since 1990 but all studies have been completed in large urban centers. We report the first Australasian stroke incidence study in a rural population. The authors applied the principle of complete ascertainment, used the WHO standard definition of stroke and classified ischemic stroke by the TOAST criteria. Data were collected from five rural centers defined by postcode of residence, over a 2-year period with 12 months of follow up of all cases. There were 217 strokes in 215 in iduals in a population of 96,036 people, over 2 years, giving a crude attack rate of 113 per 100,000 per year. The 181 first-ever strokes (83% of total), standardized to the WHO world population, occurred at a rate of 50/100,000 (95% CI: 43–58). The 28-day fatality for first-ever strokes was 24% (95% CI: 18–31) and 77% (95% CI: 71–83) were classified as ischemic (140/181), 15% (95% CI: 10–21) intracerebral hemorrhage, 3% (95% CI: 1–6) due to subarachnoid hemorrhage and 5% (95% CI: 2–9) were unknown. A high proportion of first-ever ischemic strokes (44%) were cardioembolic, mostly (77%) due to atrial arrhythmias. Of the 38 with known atrial arrhythmias prior to stroke, only six (16%) were therapeutically anticoagulated. This rural companion study of a recent Australian urban stroke incidence study confirms the downward trend of stroke incidence in Australia, and reiterates that inadequate anticoagulation of atrial arrhythmia remains a preventable cause of ischemic stroke.
Baseline blood pressure does not modify the effect of intravenous thrombolysis in successfully revascularized patients
Publisher: Frontiers Media SA
Date: 12-09-2022
DOI: 10.3389/FNEUR.2022.984599
Abstract: Studies indicate a trajectory relationship between baseline blood pressure (BP) and outcome in patients with acute ischemic stroke (AIS) eligible for both intravenous thrombolysis (IVT) with alteplase and endovascular treatment (EVT). We determined whether baseline BP modified the effect of IVT in successfully revascularized AIS patients who participated in the Direct Intra-Arterial Thrombectomy to Revascularize AIS Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals (DIECT-MT) trial. The association of baseline systolic BP, trichotomized as high (141–185 mmHg), middle (121–140 mmHg), and low (91–120 mmHg), and the outcomes of any intracerebral hemorrhage (ICH), symptomatic ICH (sICH), and mortality and functional outcome on the modified Rankin scale at 90 days were explored. Logistic regression models determined the interaction between clinical outcomes and baseline systolic and diastolic BP, and mean arterial pressure (MAP), at 10 mmHg intervals. Data are reported as odds ratios (OR) and 95% CI. A post-hoc analysis of DIRECT-MT, in 510 of the 656 randomized participants with successful revascularization underwent MT. The overall adjusted common OR of IVT and baseline BP on any ICH, sICH, and 90-day mortality and functional outcome were 0.884 (95%CI 0.613–1.274), 0.643 (95%CI 0.283–1.458), 0.842 (95%CI 0.566–1.252), and 1.286 (95%CI 0.772–2.142), respectively. No significant interaction between baseline blood pressure and intravenous thrombolysis with clinical outcome was observed. In patients with baseline SBP under 185 mmHg, baseline blood pressure does not alter the risk of hemorrhagic transformation and clinical outcome in successfully revascularized patients, regardless of intravenous alteplase usage. Future studies are needed to confirm our findings. URL: www.clinicaltrials.gov , Identifier: NCT03469206.
Blood pressure-lowering for secondary prevention of stroke: ACE inhibition is the key
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2003
Guideline for the diagnosis and management of hypertension in adults — 2016
Publisher: AMPCo
Date: 07-2016
DOI: 10.5694/MJA16.00526
Abstract: The National Heart Foundation of Australia has updated the Guide to management of hypertension 2008: assessing and managing raised blood pressure in adults (updated December 2010). Main recommendations For patients at low absolute cardiovascular disease risk with persistent blood pressure (BP) ≥ 160/100 mmHg, start antihypertensive therapy. The decision to treat at lower BP levels should consider absolute cardiovascular disease risk and/or evidence of end-organ damage, together with accurate BP assessment. For patients at moderate absolute cardiovascular disease risk with persistent systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg, start antihypertensive therapy. Treat patients with uncomplicated hypertension to a target BP of < 140/90 mmHg or lower if tolerated. Changes in management as a result of the guideline Ambulatory and/or home BP monitoring should be offered if clinic BP is ≥ 140/90 mmHg, as out-of-clinic BP is a stronger predictor of outcome. In selected high cardiovascular risk populations, aiming for a target of < 120 mmHg systolic can improve cardiovascular outcomes. If targeting < 120 mmHg, close follow-up is recommended to identify treatment-related adverse effects including hypotension, syncope, electrolyte abnormalities and acute kidney injury. Why the changes have been made A 2015 meta-analysis of patients with uncomplicated mild hypertension (systolic BP range, 140-169 mmHg) demonstrated that BP-lowering therapy is beneficial (reduced stroke, cardiovascular death and all-cause mortality). A 2015 trial comparing lower with higher blood pressure targets in selected high cardiovascular risk populations found improved cardiovascular outcomes and reduced mortality, with an increase in some treatment-related adverse events.
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2015
DOI: 10.1161/STR.0B013E3181EC611B
Abstract: Purpose— The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage. Methods— A formal literature search of MEDLINE was performed. Data were synthesized with the use of evidence tables. Writing committee members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statements Oversight Committee and Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years’ time. Results— Evidence-based guidelines are presented for the care of patients presenting with intracerebral hemorrhage. The focus was sub ided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management, preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and future considerations. Conclusions— Intracerebral hemorrhage is a serious medical condition for which outcome can be impacted by early, aggressive care. The guidelines offer a framework for goal-directed treatment of the patient with intracerebral hemorrhage.
Response to Letter by Chen et al
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2006
Effects of blood pressure lowering on intracranial and extracranial bleeding in patients on antithrombotic therapy: the PROGRESS trial.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2012
DOI: 10.1161/STROKEAHA.112.651448
Abstract: Observational studies demonstrate strong associations between blood pressure and bleeding complications of antithrombotic therapy. The objective was to determine whether blood pressure lowering reduces risks of bleeding in patients on antithrombotic therapy. This is a subsidiary analysis of the Perindopril Protection Against Recurrent Stroke Study (PROGRESS) trial, a randomized, placebo-controlled trial. A total of 6105 patients with cerebrovascular disease were randomly assigned to either active treatment (perindopril±indapamide) or placebo(s). The outcomes were intracranial and extracranial bleeding. There were 4876 (80%) patients on antithrombotic therapy at baseline. Over a mean follow-up of 3.9 years, 119 intracranial and 123 extracranial bleeding events were observed. Among patients with and without antithrombotic therapy, active treatment lowered blood pressure by 8.9/4.0 and 9.3/3.8 mm Hg and reduced the risks of intracranial bleeding by 46% (95% CI, 7%–69%) and 70% (39%–85%), respectively. However, active treatment did not reduce the risks of extracranial bleeding significantly in either group. Among patients on antithrombotic therapy, the lowest risk of intracranial bleeding was observed in participants with the lowest follow-up systolic blood pressure levels (median, 113 mm Hg). Blood pressure lowering provides protection against intracranial bleeding among patients with cerebrovascular disease including those receiving antithrombotic therapy. This trial was not registered because patients were enrolled before July 1, 2005.
Thrombolysis ImPlementation in Stroke (TIPS): evaluating the effectiveness of a strategy to increase the adoption of best evidence practice – protocol for a cluster randomised controlled trial in acut
Publisher: Springer Science and Business Media LLC
Date: 25-03-2014
Disparities in stroke incidence over time by sex and age in Latin America and the Caribbean region: a systematic review and meta-analysis
Publisher: Cold Spring Harbor Laboratory
Date: 23-02-2023
DOI: 10.1101/2023.02.23.23286066
Abstract: High-income countries studies show unfavorable trends in stroke incidence (SI) in younger populations. We aimed to estimate temporal change in SI disaggregated by age and sex in Latin America and the Caribbean region (LAC). A search strategy was used in MEDLINE, WOS, and LILACS databases from 1997 to 2021, including prospective observational studies with age and sex-disaggregated data of first-ever stroke (FES) incidence. Risk of bias was assessed with The Joanna Briggs Institute’s guide. The main outcomes were incidence rate ratio (IRR) and relative temporal trend ratio (RTTR) of SI, comparing time periods ≥2010 with . Pooled RTTR (pRTTR) only considering studies with two periods in the same population were calculated by random-effects meta-analysis. From 9,242 records identified, six studies were selected including 4,483 FES in 4,101,084 in iduals. Crude IRR in younger subjects ( years) comparing ≥2010: periods showed an increase in SI in the last decade (IRR 1.37 %CI 1.23-1.50), in contrast to a decrease in older people during the same period (IRR 0.83 95%CI 0.76–0.89). Overall RTTR ( :≥55 years) was 1.65 (95CI% 1.50-1.80), with higher increase in young women (pRTTR 3.08 95%CI 1.18-4.97 p for heterogeneity .001). An unfavorable change in SI in young people - especially in women - was detected in the last decade in LAC. Further investigation of the explanatory variables is required to ameliorate stroke prevention and inform local decision-makers. CRD42022332563 (PROSPERO).
Prognostic significance of early urinary catheterization after acute stroke: Secondary analyses of the international HeadPoST trial
Publisher: SAGE Publications
Date: 19-02-2021
Abstract: An indwelling urinary catheter (IUC) is often inserted to manage bladder dysfunction, but its impact on prognosis is uncertain. We aimed to determine the association of IUC use on clinical outcomes after acute stroke in the international, multi-center, cluster crossover, Head Positioning in Acute Stroke Trial (HeadPoST). Data were analyzed on HeadPoST participants (n = 11,093) randomly allocated to the lying-flat or sitting-up head position. Binomial, logistic regression, hierarchical mixed models were used to determine associations of early insertion of IUC within seven days post-randomization and outcomes of death or disability (defined as “poor outcome,” scores 3–6 on the modified Rankin scale) and any urinary tract infection at 90 days with adjustment of baseline and post-randomization management covariates. Overall, 1167 (12%) patients had an IUC, but the frequency and duration of use varied widely across patients in different regions. IUC use was more frequent in older patients, and those with vascular comorbidity, greater initial neurological impairment (on the National Institutes of Health Stroke Scale), and intracerebral hemorrhage as the underlying stroke type. IUC use was independently associated with poor outcome (adjusted odds ratio (aOR): 1.40, 95% confidence interval (CI): 1.13–1.74), but not with urinary tract infection after adjustment for antibiotic treatment and stroke severity at hospital separation (aOR: 1.13, 95% CI: 0.59–2.18). The number exposed to IUC for poor outcome was 13. IUC use is associated with a poor outcome after acute stroke. Further studies are required to inform appropriate use of IUC.
Risk-Adjusted hospital mortality rates for stroke: Evidence from the Australian Stroke Clinical Registry (AuSCR)
Publisher: AMPCo
Date: 05-2017
DOI: 10.5694/MJA16.00525
Abstract: Hospital data used to assess regional variability in disease management and outcomes, including mortality, lack information on disease severity. We describe variance between hospitals in 30-day risk-adjusted mortality rates (RAMRs) for stroke, comparing models that include or exclude stroke severity as a covariate. Cohort design linking Australian Stroke Clinical Registry data with national death registrations. Multivariable models using recommended statistical methods for calculating 30-day RAMRs for hospitals, adjusted for demographic factors, ability to walk on admission, stroke type, and stroke recurrence. Australian hospitals providing at least 200 episodes of acute stroke care, 2009-2014. Hospital RAMRs estimated by different models. Changes in hospital rank order and funnel plots were used to explore variation in hospital-specific 30-day RAMRs that is, RAMRs more than three standard deviations from the mean. In the 28 hospitals reporting at least 200 episodes of care, there were 16 218 episodes (15 951 patients median age, 77 years women, 46% ischaemic strokes, 79%). RAMRs from models not including stroke severity as a variable ranged between 8% and 20% RAMRs from models with the best fit, which included ability to walk and stroke recurrence as variables, ranged between 9% and 21%. The rank order of hospitals changed according to the covariates included in the models, particularly for those hospitals with the highest RAMRs. Funnel plots identified significant deviation from the mean overall RAMR for two hospitals, including one with borderline excess mortality. Hospital stroke mortality rates and hospital performance ranking may vary widely according to the covariates included in the statistical analysis.
Treatment of chronic subdural hematoma with atorvastatin combined with low-dose dexamethasone: phase II randomized proof-of-concept clinical trial
Publisher: Journal of Neurosurgery Publishing Group (JNSPG)
Date: 2021
DOI: 10.3171/2019.11.JNS192020
Abstract: The authors sought to test the hypothesis that adding dexamethasone (DXM) to atorvastatin (ATO) potentiates the effects of ATO on chronic subdural hematoma (CSDH). Sixty patients with CSDH underwent 5 weeks of treatment with an additional 7-week follow-up. Patients were randomized to receive a 5-week regimen of ATO 20 mg daily or ATO 20 mg daily plus a DXM regimen (ATO+DXM). The 5-week DXM regimen was 2.25 mg daily for 2 consecutive weeks, followed by 0.75 mg twice daily for 2 weeks and 0.75 mg once daily for 1 week. The primary endpoint was hematoma reduction assessed by neuroimaging at baseline and at 5 weeks of follow-up. Secondary outcomes included neurological improvement assessed by using the Markwalder’s Grading Scale and Glasgow Coma Scale (MGS-GCS). The mean patient age was 66.6 years, and 25% of patients were women. The patients who were treated with ATO+DXM had more obvious hematoma reduction at the 5th week (between-groups difference 18.37 ml 95% CI 8.17–28.57 p = 0.0005). This reduction started from the 2nd week (14.51 ml 95% CI 4.31–24.71 p = 0.0056) of treatment and persisted until the 12th week (17.50 ml 95% CI 7.30–27.70 p = 0.0009). Complete recovery of neurological function (MGS-GCS grade 0) at 5 weeks was achieved in 83.33% and 32.14% of patients in the ATO+DXM and ATO groups, respectively. At the 5th week, patients receiving ATO+DXM had significantly lower levels of T cells and higher levels of regulatory T cells and endothelial progenitor cells in their peripheral blood. ATO+DXM was more effective than ATO alone in reducing hematoma and improving neurological function in patients with CSDH. These results require further confirmation in a randomized placebo-controlled trial. Clinical trial registration no.: ChiCTR-IPR-14005573 ( www.chictr.org.cn/index.aspx )
Incidence and risks of subarachnoid hemorrhage in China.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2013
DOI: 10.1161/STROKEAHA.113.002599
Abstract: To determine incidence and risks of subarachnoid hemorrhage in China. A prospective, population-based, 1:2 matched case–control study in Baotou, Inner Mongolia (≈2 million population) in 2009–2011. Multiple variable models used to determine relative risk and population-attributable risks for exposures. For a total of 226 patients (mean age, 59 years 65% women 434 controls), crude annual incidence (per 100 000) of subarachnoid hemorrhage was 6.2 (95% confidence intervals, 5.4–7.0) 4.3 (3.3–5.2) for men and 8.2 (6.9–9.6) for women. Compared with nonsmokers, adjusted relative risk of subarachnoid hemorrhage in current smokers was 2.31 (95% confidence interval, 1.31–4.09) but was 4.00 (1.62–9.89) in women. Population-attributable risk for smoking, hypertension, and low income were 18%, 36% and 59%, respectively. The incidence of subarachnoid hemorrhage in China is slightly lower than in Western countries and is related to smoking, hypertension, and poor socioeconomic status.
Cost-Effectiveness of Low-Dose Compared to Standard-Dose Alteplase for Acute Ischemic Stroke in China: A Within-Trial Economic Evaluation of the ENCHANTED Study
Publisher: S. Karger AG
Date: 31-08-2023
DOI: 10.1159/000525869
Abstract: b i Introduction: /i /b The Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED) showed that a low-dose alteplase was safe but not clearly non-inferior to standard-dose alteplase in acute ischemic stroke (AIS). Given the significant cost of this medicine, we undertook a cost-effectiveness analysis to determine the probability that low-dose is cost-effective relative to standard-dose alteplase in China. b i Methods: /i /b For ENCHANTED participants in China with available health cost data, cost-effectiveness and cost-utility analyses were undertaken in which death or disability (modified Rankin scale scores 2–6) at 90 days and quality-adjusted life-years (QALYs) were used as outcome measures, respectively. There was adherence to standard guidelines for health economic evaluations alongside non-inferiority trials and according to a health-care payer’s perspective. The equivalence margin for cost and effectiveness was set at USD 691 and −0.025 QALYs, respectively, for the base-case analysis. Probabilistic sensitivity analyses were used to evaluate the probability of low-dose alteplase being non-inferior. b i Results: /i /b While the mean cost of alteplase was lower in the low-dose group (USD 1,569 vs. USD 2,154 in the standard-dose group), the total cost was USD 56 (95% confidence interval [CI]: −1,000–1,113) higher compared to the standard-dose group due to higher hospitalization costs in the low-dose group. There were 462 (95% CI: 415–509) and 410 (95% CI: 363–457) patients with death or disability per 1,000 patients in the low-dose and standard-dose groups, respectively. The low-dose group had marginally lower (0.008, 95% CI: −0.016–0.001) QALYs compared to their standard-dose counterparts. The low-dose group was found to have an 88% probability of being non-inferior based on cost-effectiveness versus the standard-dose group. b i Conclusions: /i /b This health economic evaluation alongside the ENCHANTED indicates that the use of low-dose alteplase does not save overall healthcare costs nor lead to a gain in QALYs in the management of Chinese patients with AIS compared to the use of standard dose. There is little justification on economic grounds to shift from standard-of-care thrombolysis in AIS.
Early lowering of blood pressure after acute intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data
Publisher: BMJ
Date: 03-11-2021
Abstract: To summarise evidence of the effects of blood pressure (BP)-lowering interventions after acute spontaneous intracerebral haemorrhage (ICH). A prespecified systematic review of the Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE databases from inception to 23 June 2020 to identify randomised controlled trials that compared active BP-lowering agents versus placebo or intensive versus guideline BP-lowering targets for adults days after ICH onset. The primary outcome was function (distribution of scores on the modified Rankin scale) 90 days after randomisation. Radiological outcomes were absolute ( mL) and proportional ( %) haematoma growth at 24 hours. Meta-analysis used a one-stage approach, adjusted using generalised linear mixed models with prespecified covariables and trial as a random effect. Of 7094 studies identified, 50 trials involving 11 494 patients were eligible and 16 (32.0%) shared patient-level data from 6221 (54.1%) patients (mean age 64.2 [SD 12.9], 2266 [36.4%] females) with a median time from symptom onset to randomisation of 3.8 hours (IQR 2.6–5.3). Active/intensive BP-lowering interventions had no effect on the primary outcome compared with placebo/guideline treatment (adjusted OR for unfavourable shift in modified Rankin scale scores: 0.97, 95% CI 0.88 to 1.06 p=0.50), but there was significant heterogeneity by strategy (p interaction =0.031) and agent (p interaction .0001). Active/intensive BP-lowering interventions clearly reduced absolute ( ml, adjusted OR 0.75, 95%CI 0.60 to 0.92 p=0.0077) and relative (≥33%, adjusted OR 0.82, 95%CI 0.68 to 0.99 p=0.034) haematoma growth. Overall, a broad range of interventions to lower BP within 7 days of ICH onset had no overall benefit on functional recovery, despite reducing bleeding. The treatment effect appeared to vary according to strategy and agent. CRD42019141136.
The Magnitude of Blood Pressure Reduction Predicts Poor In-Hospital Outcome in Acute Intracerebral Hemorrhage
Publisher: Springer Science and Business Media LLC
Date: 10-06-2020
Acute post-stroke blood pressure relative to premorbid levels in intracerebral haemorrhage versus major ischaemic stroke: A population-based study
Publisher: Elsevier BV
Date: 04-2014
Early Cognitive Impairment after Intracerebral Hemorrhage in the INTERACT1 Study
Publisher: S. Karger AG
Date: 2017
DOI: 10.1159/000481443
Abstract: b i Background: /i /b Data on cognitive impairment after acute intracerebral hemorrhage (ICH) are limited. This study is aimed at determining the frequency and predictors of cognitive impairment among participants of the pilot phase, Intensive Blood Pressure (BP) Reduction in Acute Cerebral Hemorrhage Trial (INTERACT1). b i Methods: /i /b INTERACT1 was an open randomized trial of early intensive (target systolic BP & #x3c mm Hg) compared with contemporaneous guideline-recommended BP lowering in 404 patients with elevated systolic BP (150–220 mm Hg) within 6 h of ICH onset. Cognitive impairment was defined by scores ≤24 on the Mini-Mental State Examination (MMSE) assessed by interview on follow-up at 90 days. b i Results: /i /b A total of 231 (64.5%) of 358 90-day survivors had MMSE scores for analyses, and 75 (32.5%) had cognitive impairment. In multivariable analysis, older age (OR 2.48, 95% CI 1.73–3.56 per 10-year increase i /i & #x3c 0.001), female sex (OR 2.06, 95% CI 1.00–4.23 i /i = 0.049), prior ICH (OR 2.87, 95% CI 1.08–7.65 i /i = 0.035), high baseline National Institute of Health Stroke Scale score (OR 1.06, 95% CI 1.00–1.13 i /i = 0.044), and high mean systolic BP over the first 24 h post-randomization (OR 1.34, 95% CI 1.07–1.68/10 mm Hg increase i /i = 0.011) were independently associated with cognitive impairment. b i Conclusions: /i /b One third of patients have significant cognitive impairment early after ICH, which is more frequent in the elderly, females, those with prior ICH, and more severe initial neurological deficit and with persistently high early systolic BP.
Preconception diabetes mellitus and adverse pregnancy outcomes in over 6.4 million women: A population-based cohort study in China
Publisher: Public Library of Science (PLoS)
Date: 10-2019
Selenium and zinc in hair and toenails in relation to the physical and mental health status of older adults: The Freemasons Health study in New Zealand
Publisher: Wiley
Date: 22-11-2007
Air Pressure, Humidity and Stroke Occurrence: A Systematic Review and Meta-Analysis
Publisher: MDPI AG
Date: 05-07-2016
Observed Cost and Variations in Short Term Cost-Effectiveness of Therapy for Ischemic Stroke in Interventional Management of Stroke (IMS) III
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-05-2017
Abstract: Examination of linked data on patient outcomes and cost of care may help identify areas where stroke care can be improved. We report on the association between variations in stroke severity, patient outcomes, cost, and treatment patterns observed over the acute hospital stay and through the 12‐month follow‐up for subjects receiving endovascular therapy compared to intravenous tissue plasminogen activator alone in the IMS (Interventional Management of Stroke) III Trial. Prospective data collected for a prespecified economic analysis of the trial were used. Data included hospital billing records for the initial stroke admission and subsequent detailed resource use after the acute hospitalization collected at 3, 6, 9, and 12 months. Cost of follow‐up care varied 6‐fold for patients in the lowest (0–1) and highest (20+) National Institutes of Health Stroke Scale category at 5 days, and by modified Rankin Scale at 3 months. The kind of resources used postdischarge also varied between treatment groups. Incremental short‐term cost‐effectiveness ratios varied greatly when treatments were compared for patient subgroups. Patient subgroups predefined by stroke severity had incremental cost‐effectiveness ratios of $97 303/quality‐adjusted life year (severe stroke) and $3 187 805/quality‐adjusted life year (moderately severe stroke). Detailed economic and resource utilization data from IMS III provide powerful evidence for the large effect that patient outcome has on the economic value of medical and endovascular reperfusion therapies. These data can be used to inform process improvements for stroke care and to estimate the cost‐effectiveness of endovascular therapy in the US health system for stroke intervention trials. URL : www.clinicaltrials.gov . Registration number: NCT 00359424.
Effects of the endpoint adjudication process on the results of a randomised controlled trial: the ADVANCE trial.
Publisher: Public Library of Science (PLoS)
Date: 04-02-2013
Interventions for Treating Depression After Stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2009
Feasibility of electrical impedance tomography in haemorrhagic stroke treatment using adaptive mesh
Publisher: IOP Publishing
Date: 04-2010
Frequency of depression after stroke: A systematic review of observational studies
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2005
DOI: 10.1161/01.STR.0000165928.19135.35
Abstract: Background and Purpose— Although depression is an important sequelae of stroke, there is uncertainty regarding its frequency and outcome. Methods— We undertook a systematic review of all published nonexperimental studies (to June 2004) with prospective consecutive patient recruitment and quantification of depressive symptoms/illness after stroke. Results— Data were available from 51 studies (reported in 96 publications) conducted between 1977 and 2002. Although frequencies varied considerably across studies, the pooled estimate was 33% (95% confidence interval, 29% to 36%) of all stroke survivors experiencing depression. Differences in case mix and method of mood assessment could explain some of the variation in estimates across studies. The data also suggest that depression resolves spontaneously within several months of onset in the majority of stroke survivors, with few receiving any specific antidepressant therapy or active management. Conclusions— Depression is common among stroke patients, with the risks of occurrence being similar for the early, medium, and late stages of stroke recovery. There is a pressing need for further research to improve clinical practice in this area of stroke care.
Genome screen in familial intracranial aneurysm
Publisher: Springer Science and Business Media LLC
Date: 13-01-2009
No benefit of flat head positioning in early moderate-severe acute ischaemic stroke: A HeadPoST study subgroup analysis
Publisher: BMJ
Date: 25-06-2020
Abstract: Although the Head Positioning in acute Stroke Trial (HeadPoST) showed no effect of the flat head position (FP vs sitting up head position (SUP)) on functional outcome, we hypothesised that it could still offer benefits if commenced early in those with acute ischaemic stroke (AIS) of at least moderate severity. Subgroup analysis of HeadPoST in participants with National Institutes of Health Stroke Scale (NIHSS) scores ≥7, ≥10 and ≥14, randomised to FP or SUP .5 hours of AIS onset on functional outcomes defined by a shift in scores on the modified Rankin scale (mRS) and death/disability (mRS scores 3–6), and any cardiovascular serious adverse event. Logistic regression analyses were undertaken adjusted for study design and baseline risk factors. There was no significant differential treatment effect in patient subgroups defined by increasing baseline NIHSS scores: adjusted OR and 95% CI for ordinal shift and binary (3–6) mRS scores: for NIHSS ≥7 (n=867) 0.92 (0.67 to 1.25) and 0.74 (0.52 to 1.04) NIHSS ≥ 10 (n=606) 0.80 (0.58 to 1.10) and 0.77 (0.49 to 1.19) NIHSS ≥14 (n=378) 0.82 (0.54 to 1.24) and 1.22 (0.69 to 2.14). Early FP had no significant effect in patients with moderate–severe AIS. NCT02162017 .
More indirect evidence of potential neuroprotective benefits of angiotensin receptor blockers
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2010
Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack
Publisher: Elsevier BV
Date: 09-2001
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2015
DOI: 10.1161/STR.0000000000000069
Abstract: The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage. A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee. Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated. Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.
Differences in the pre-hospital management of women and men with stroke by emergency medical services in New South Wales
Publisher: Wiley
Date: 13-07-2022
DOI: 10.5694/MJA2.51652
Abstract: To examine whether pre-hospital emergency medical service care differs for women and men subsequently admitted to hospital with stroke. Population-based cohort study analysis of linked Admitted Patient Data Collection and NSW Ambulance data for people admitted to New South Wales hospitals with a principal diagnosis of stroke at separation, 1 July 2005 - 31 December 2018. Emergency medical service assessments, protocols, and management for patients subsequently diagnosed with stroke, by sex. Of 202 231 people hospitalised with stroke (mean age, 73 [SD, 14] years 98 599 women [51.0%]), 101 357 were conveyed to hospital by ambulance (50.1%). A larger proportion of women than men travelled by ambulance (52.4% v 47.9% odds ratio [OR], 1.09 95% CI, 1.07-1.11), but time between the emergency call and emergency department admission was similar for both sexes. The likelihood of being assessed as having a stroke (adjusted OR [aOR], 0.97 95% CI, 0.93-1.01) or subarachnoid haemorrhage (aOR, 1.22 95% CI, 0.73-2.03) was similar for women and men, but women under 70 years of age were less likely than men to be assessed as having a stroke (aOR, 0.89 95% CI, 0.82-0.97). Women were more likely than men to be assessed by paramedics as having migraine, other headache, anxiety, unconsciousness, hypertension, or nausea. Women were less likely than men to be managed according to the NSW Ambulance pre-hospital stroke care protocol (aOR, 0.95 95% CI, 0.92-0.97), but the likelihood of basic pre-hospital care was similar for both sexes (aOR, 1.01 95% CI, 0.99-1.04). Our large population-based study identified sex differences in pre-hospital management by emergency medical services of women and men admitted to hospital with stroke. Paramedics should receive training that improves the recognition of stroke symptoms in women.
Treatment and Outcomes of Working Aged Adults with Stroke: Results from a National Prospective Registry
Publisher: S. Karger AG
Date: 2017
DOI: 10.1159/000484141
Abstract: b i Background: /i /b Given the potential differences in etiology and impact, the treatment and outcome of younger patients (aged 18–64 years) require examination separately to older adults (aged ≥65 years) who experience acute stroke. b i Methods: /i /b i /i Data from the Australian Stroke Clinical Registry (2010–2015) including demographic and clinical characteristics, provision of evidence-based therapies and health-related quality of life (HRQoL) post-stroke was used. Descriptive statistics and multilevel regression models were used for group comparisons. b i Results: /i /b Compared to older patients (age ≥65 years) among 26,220 registrants, 6,526 (25%) younger patients (age 18–64 years) were more often male (63 vs. 51% i /i & #x3c 0.001), born in Australia (70 vs. 63% i /i & #x3c 0.001), more often discharged home from acute care (56 vs. 38% i /i & #x3c 0.001), and less likely to receive antihypertensive medication (61 vs. 73% i /i & #x3c 0.001). Younger patients had a 74% greater odds of having lower HRQoL compared to an equivalent aged-matched general population (adjusted OR 1.74, 95% CI 1.56–1.93, i /i & #x3c 0.001). b i Conclusions: /i /b i /i Younger stroke patients exhibited distinct differences from their older counterparts with respect to demographic and clinical characteristics, prescription of antihypertensive medications and residual health status.
Indobufen versus aspirin in patients with acute ischaemic stroke in China (INSURE): a randomised, double-blind, double-dummy, active control, non-inferiority trial
Publisher: Elsevier BV
Date: 06-2023
Chronic Care and Risk Factor Management in Cardiovascular Disease
Publisher: Elsevier BV
Date: 10-2012
Cerebrovascular Disease in Hypertension
Publisher: Elsevier
Date: 2007
The economic impact of epilepsy: A systematic review
Publisher: Springer Science and Business Media LLC
Date: 25-11-2015
Adelaide Stroke Incidence Study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2013
DOI: 10.1161/STROKEAHA.113.675140
Abstract: Stroke incidence rates are in flux worldwide because of evolving risk factor prevalence, risk factor control, and population aging. Adelaide Stroke Incidence Study was performed to determine the incidence of strokes and stroke subtypes in a relatively elderly population of 148 000 people in the Western suburbs of Adelaide. All suspected strokes were identified and assessed in a 12-month period from 2009 to 2010. Standard definitions for stroke and stroke fatality were used. Ischemic stroke pathogenesis was classified by the Trial of ORG 10172 in Acute Stroke Treatment criteria. There were 318 stroke events recorded in 301 in iduals 238 (75%) were first-in-lifetime events. Crude incidence rates for first-ever strokes were 161 per 100 000 per year overall (95% confidence interval [CI], 141–183), 176 for men (95% CI, 147–201), and 146 for women (95% CI, 120–176). Adjusted to the world population rates were 76 overall (95% CI, 59–94), 91 for men (95% CI, 73–112), and 61 for women (95% CI, 47–78). The 28-day case fatality rate for first-ever stroke was 19% (95% CI, 14–24) the majority were ischemic (84% [95% CI, 78–88]). Intracerebral hemorrhage comprised 11% (8–16), subarachnoid hemorrhage 3% (1–6), and 3% (1–6) were undetermined. Of the 258 ischemic strokes, 42% (95% CI, 36–49) were of cardioembolic pathogenesis. Atrial fibrillation accounted for 36% of all ischemic strokes, of which 85% were inadequately anticoagulated. Stroke incidence in Adelaide has not increased compared with previous Australian studies, despite the aging population. Cardioembolic strokes are becoming a higher proportion of all ischemic strokes.
The place of site of lesion in the aetiology of post-stroke depression
Publisher: S. Karger AG
Date: 1996
DOI: 10.1159/000108023
Implications of INTERACT2 and other clinical trials: Blood pressure management in acute intracerebral hemorrhage
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2015
European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage
Publisher: SAGE Publications
Date: 11-05-2021
DOI: 10.1177/23969873211012133
Abstract: The optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH) remains controversial. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions regarding BP management in acute stroke. The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. Despite several large randomised-controlled clinical trials, quality of evidence is generally low due to inconsistent results of the effect of blood pressure lowering in AIS. We recommend early and modest blood pressure control (avoiding blood pressure levels /105 mm Hg) in AIS patients undergoing reperfusion therapies. There is more high-quality randomised evidence for BP lowering in acute ICH, where intensive blood pressure lowering is recommended rapidly after hospital presentation with the intent to improve recovery by reducing haematoma expansion. These guidelines provide further recommendations on blood pressure thresholds and for specific patient subgroups. There is ongoing uncertainty regarding the most appropriate blood pressure management in AIS and ICH. Future randomised-controlled clinical trials are needed to inform decision making on thresholds, timing and strategy of blood pressure lowering in different acute stroke patient subgroups.
Neuroprotection by angiotensin receptor blockers?
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2008
TACTICS - Trial of Advanced CT Imaging and Combined Education Support for Drip and Ship: evaluating the effectiveness of an ‘implementation intervention’ in providing better patient access to reperfus
Publisher: BMJ
Date: 02-2022
DOI: 10.1136/BMJOPEN-2021-055461
Abstract: Stroke reperfusion therapies, comprising intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT), are best practice treatments for eligible acute ischemic stroke patients. In Australia, EVT is provided at few, mainly metropolitan, comprehensive stroke centres (CSC). There are significant challenges for Australia’s rural and remote populations in accessing EVT, but improved access can be facilitated by a ‘drip and ship’ approach. TACTICS (Trial of Advanced CT Imaging and Combined Education Support for Drip and Ship) aims to test whether a multicomponent, multidisciplinary implementation intervention can increase the proportion of stroke patients receiving EVT. This is a non-randomised controlled, stepped wedge trial involving six clusters across three Australian states. Each cluster comprises one CSC hub and a minimum of three primary stroke centre (PSC) spokes. Hospitals will work in a hub and spoke model of care with access to a multislice CT scanner and CT perfusion image processing software (MIStar, Apollo Medical Imaging). The intervention, underpinned by behavioural theory and technical assistance, will be allocated sequentially, and clusters will move from the preintervention (control) period to the postintervention period. Proportion of all stroke patients receiving EVT, accounting for clustering. Proportion of patients receiving IVT at PSCs, proportion of treated patients (IVT and/or EVT) with good (modified Rankin Scale (mRS) score 0–2) or poor (mRS score 5–6) functional outcomes and European Quality of Life Scale scores 3 months postintervention, proportion of EVT-treated patients with symptomatic haemorrhage, and proportion of reperfusion therapy-treated patients with good versus poor outcome who presented with large vessel occlusion at spokes. Ethical approval has been obtained from the Hunter New England Human Research Ethics Committee (18/09/19/4.13, HREC/18/HNE/241, 2019/ETH01238). Trial results will be disseminated widely through published manuscripts, conference presentations and at national and international platforms regardless of whether the trial was positive or neutral. ACTRN12619000750189 UTNU1111-1230-4161.
Effects of blood pressure lowering on major vascular events among patients with isolated diastolic hypertension: the perindopril protection against recurrent stroke study (PROGRESS) trial.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2011
DOI: 10.1161/STROKEAHA.110.606764
Abstract: Despite clear evidence that blood pressure (BP) lowering is effective for prevention of cardiovascular events among patients with isolated systolic hypertension and systolic–diastolic hypertension, there is ongoing uncertainty about its effects in those with isolated diastolic hypertension. The objective of the present analysis is to determine whether BP lowering provides benefits to patients with isolated diastolic hypertension. Patients with cerebrovascular disease and hypertension at baseline (n=4283) were randomly assigned to either active treatment (perindopril in all participants plus indapamide for those with neither an indication for nor a contraindication to a diuretic) or matching placebo(s). The primary outcome was total major vascular events. There were 1923 patients with isolated systolic hypertension (systolic BP ≥140 mm Hg and diastolic BP mm Hg), 315 with isolated diastolic hypertension (systolic BP mm Hg and diastolic BP ≥90 mm Hg), and 2045 with systolic–diastolic hypertension (systolic BP ≥140 mm Hg and diastolic BP ≥90 mm Hg) at baseline. Active treatment reduced the relative risk of major vascular events by 27% (95% CI, 10% to 41%) among patients with isolated systolic hypertension, by 28% (−29% to 60%) among those with isolated diastolic hypertension, and by 32% (17% to 45%) among those with systolic–diastolic hypertension. There was no evidence of differences in the magnitude of the effects of treatment among different types of hypertension ( P homogeneity=0.89). BP lowering is likely to provide a similar level of protection against major vascular events for patients with isolated diastolic hypertension as for those with isolated systolic hypertension and systolic–diastolic hypertension. This trial was not registered because patients were enrolled before July 1, 2005.
Circadian variation in clinical features and outcome of intracerebral hemorrhage: The INTERACT studies
Publisher: Informa UK Limited
Date: 02-08-2016
DOI: 10.1080/07420528.2016.1210158
Abstract: Previous studies consistently reported a diurnal variation in the occurrence of intracerebral hemorrhage (ICH), with a morning peak. However, limited knowledge exists on the circadian pattern of ICH severity and outcome. This study aimed to determine possible associations between ICH onset time and admission severity and 90-day outcomes using the combined data set of the pilot and main-phase Intensive blood pressure (BP) reduction in an acute cerebral hemorrhage trial (INTERACT). The ICH onset time was categorized into three groups (1: 00:00-07:59 2: 08:00-15:59 and 3: 16:00-23:59). We found an association between onset time and low Glasgow Coma Scale score: aOR (time 1: 1.72, 95% CI 1.12-2.66 time 3: 1.95, 95% CI 1.31-2.89, p = 0.003 in comparison to time 2). There was no association between onset time and volume of ICH (adjusted p = 0.354) or 90-day outcomes of death or major disability, and death and major disability separately (all adjusted p > 0.4). The results showed that more severe cases of ICH patients, defined by a reduced level of consciousness, had late afternoon to early morning stroke onset, but this was unrelated to baseline hematoma volume or location. There was no circadian influence on ICH clinical outcome.
Australian Men’s Sheds and Their Role in the Health and Wellbeing of Men: A Systematic Review
Publisher: Hindawi Limited
Date: 27-03-2023
DOI: 10.1155/2023/2613413
Abstract: Men’s sheds are a community-based organisation that allows a space for a community of men to interact and engage with one another with hands-on activities. As such, men’s sheds form an appropriate setting to deliver health and wellbeing initiatives. This review aims to understand the role of Australian men’s sheds with respect to the health and wellbeing of their male participants. This review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analysis (PRISMA) following a three-step process of planning, conducting, and reporting the review. All three authors reviewed all the eligible articles. There was significant methodological heterogeneity between the sources identified (n = 11). A narrative synthesis identified three key themes: health promotion, wellbeing, and socialisation intergenerational mentoring and Aboriginal and Torres Strait Islander men’s health. Men’s sheds serve as ideal locations for the delivery of initiatives that can positively impact on the health and wellbeing of their male participants. Furthermore, research is needed to explore the implementation and evaluation of these health and wellbeing initiatives for men in their respective communities.
Location and Size of Ruptured Intracranial Aneurysm and Serious Clinical Outcomes Early after Subarachnoid Hemorrhage: A Population-Based Study in Australasia
Publisher: S. Karger AG
Date: 2011
DOI: 10.1159/000324938
Abstract: i Background: /i It is uncertain whether the location and size of a ruptured intracranial aneurysm (IA) independently influences the outcome of subarachnoid hemorrhage (SAH). i Objective: /i To determine the independent relationship of location and size of a ruptured IA with serious clinical outcomes after SAH in an Australasian population-based study. i Methods: /i From 432 first-ever cases of primary SAH registered prospectively over 12 months in 4 Australasian cities between 1995 and 1998, the demographics, clinical features, risk factors and results of investigations were obtained, including the location and size of any ruptured IA as assessed by cerebral angiography, computed tomography and/or magnetic resonance imaging. Location was classified as either anterior (i.e. anterior communicating artery, internal carotid artery and middle cerebral artery) or posterior circulation (i.e. posterior communicating artery, posterior inferior cerebellar artery, basilar artery and vertebral artery), and size was classified as , 5–9 and ≧10 mm. Outcomes recorded during hospitalization were rebleeding, delayed ischemia, hydrocephalus, residual neurological impairment and in-hospital death. Logistic regression analysis was used to evaluate the effects of IA location and size on outcome, independent of other potential prognostic factors. Data are reported with odds ratios (OR) and 95% confidence intervals (CI). i Results: /i IA location and size were confirmed separately in 299 and 252 patients, respectively. Patients with a posterior circulation IA had a lower rate of rebleeding than those with an anterior circulation IA (adjusted OR: 0.11 95% CI: 0.02–0.87), but otherwise there was no significant relationship between IA location and outcome. Patients with a larger ruptured IA had higher risks of rebleeding (p = 0.02 for trend) and in-hospital death (p = 0.001) after controlling for age, sex, ethnicity, location of the ruptured IA and neurosurgical intervention. i Conclusion: /i IA location in the posterior circulation was associated with a lower risk of rebleeding than IA in the anterior circulation. A larger IA size was associated with higher risks of rebleeding and in-hospital death.
Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke
Publisher: Massachusetts Medical Society
Date: 22-06-2017
Blood pressure lowering in acute phase of stroke: Latest evidence and clinical implications
Publisher: SAGE Publications
Date: 07-2012
Abstract: Persistent controversy exists as to whether there are worthwhile beneficial effects of early, rapid lowering of elevated blood pressure (BP) in acute stroke. Elevated BP or ‘hypertension’ (i.e. systolic mmHg) is common in stroke, especially in patients with pre-existing hypertension and large strokes, due to variable ‘autonomic stress’ and raised intracranial pressure. While positive associations between BP levels and poor outcomes are evident across a range of studies, very low BP levels and large reductions in BP have also been shown to predict death and dependence, more so for ischaemic stroke (IS) than intracerebral haemorrhage (ICH). Accumulating evidence indicates that early BP lowering can reduce haematoma expansion in ICH, but there is uncertainty over whether this translates into improved clinical outcomes, particularly since such an effect was not evident from haemostatic therapy in clinical trials. Guidelines generally recommend control of high systolic BP ( mmHg), but recent evidence indicates that even more modest elevation ( mmHg) increases risks of cerebral oedema and haemorrhagic transformation following thrombolysis in IS. Thus, any potential benefits of rapid BP lowering in acute stroke, particularly in IS, must be balanced against the potential risks of worsening cerebral ischaemia from altered autoregulation erfusion. This paper explores current knowledge regarding the management of hypertension in acute stroke and introduces ongoing clinical trials aimed at resolving such a critical issue in the care of patients with acute stroke.
Increased recurrent risk did not improve cerebrovascular disease survivors' response to stroke in China: a cross-sectional, community-based study.
Publisher: Springer Science and Business Media LLC
Date: 21-04-2020
DOI: 10.1186/S12883-020-01724-1
Abstract: Cerebrovascular disease (CVD) survivors are at a high risk of recurrent stroke. Although it is thought that survivors with higher risk of stroke respond better to stroke onset, to date, no study has been able to demonstrate that. Thus, we investigated whether the intent to call emergency medical services (EMS) increased with recurrent stroke risk among CVD survivors. A cross-sectional community-based survey was conducted from January 2017 to May 2017, including 187,723 adults (age ≥ 40 years) across 69 administrative areas in China. A CVD survivor population of 6290 was analyzed. According to the stroke risk score based on Essen Stroke Risk Score, CVD survivors were ided into three subgroups: low (0), middle (1–3) and high (4–7) recurrent risk groups. Multivariable logistic regression models were used to identify the association between the stroke risk and stroke recognition, as well as stroke risk and EMS calling. The estimated stroke recognition rate in CVD survivors with low, middle, and high risk was 89.0% (503/565), 85.2% (3841/4509), and 82.5% (1001/1213), respectively, while the rate of calling EMS was 66.7% (377/565), 64.3% (2897/4509), and 69.3% (840/1213), respectively. The CVD survivors’ knowledge of recognizing stroke and intent to call EMS did not improve with recurrent stroke risk, even after adjustment for multiple socio-demographic factors. Despite being at a higher risk of recurrent stroke, Chinese CVD survivors showed poor knowledge of stroke, and their intent to call EMS did not increase with recurrent stroke risk. Enhanced and stroke risk-orientated education on stroke recognition and proper response is needed for all CVD survivors.
Sex differences in pain expressed by patients across diverse disease states: individual patient data meta-analysis of 33,957 participants in 10 randomized controlled trials
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 24-03-2023
DOI: 10.1097/J.PAIN.0000000000002884
Abstract: The experience of pain is determined by many factors and has a significant impact on quality of life. This study aimed to determine sex differences in pain prevalence and intensity reported by participants with erse disease states in several large international clinical trials. In idual participant data meta-analysis was conducted using EuroQol-5 Dimension (EQ-5D) questionnaire pain data from randomised controlled trials published between January 2000 and January 2020 and undertaken by investigators at the George Institute for Global Health. Proportional odds logistic regression models, comparing pain scores between females and males and fitted with adjustments for age and randomized treatment, were pooled in a random-effects meta-analysis. In 10 trials involving 33,957 participants (38% females) with EQ-5D pain score data, the mean age ranged between 50 and 74. Pain was reported more frequently by females than males (47% vs 37% P 0.001). Females also reported greater levels of pain than males (adjusted odds ratio 1.41, 95% CI 1.24-1.61 P 0.001). In stratified analyses, there were differences in pain by disease group ( P for heterogeneity .001), but not by age group or region of recruitment. Females were more likely to report pain, and at a higher level, compared with males across erse diseases, all ages, and geographical regions. This study reinforces the importance of reporting sex-disaggregated analysis to identify similarities and differences between females and males that reflect variable biology and may affect disease profiles and have implications for management.
Safety and efficacy of routine postoperative ibuprofen for pain and disability related to ectopic bone formation after hip replacement surgery (HIPAID): Randomised controlled trial
Publisher: BMJ
Date: 02-08-2006
Degree of blood pressure reduction and recurrent stroke: the PROGRESS trial.
Publisher: BMJ
Date: 14-05-2014
Abstract: There is ongoing controversy regarding a 'J-curve' phenomenon such that low and high blood pressure (BP) levels are associated with increased risks of recurrent stroke. We aimed to determine whether large treatment-related BP reductions are associated with increased risks of recurrent stroke. Data are from the PROGRESS trial, where 6105 patients with cerebrovascular disease were randomly assigned to either active treatment (perindopril ± indapamide) or placebo(s). There were no BP criteria for entry. BP was measured at every visit, and participant groups defined by reduction in systolic BP (SBP) from baseline were used for the analyses. Outcome was recurrent stroke. During a mean follow-up of 3.9 years, 727 recurrent strokes were observed. There were clear associations between the magnitude of SBP reduction and the risk of recurrent stroke. After adjustment for cardiovascular risk factors and randomised treatment, annual incidence was 2.08%, 2.10%, 2.31% and 2.96% for participant groups defined by SBP reductions of ≥ 20, 10-19, 0-9 and <0 mm Hg, respectively (p=0.0006 for trend). The present analysis provided no evidence of an increase in recurrent stroke associated with larger reductions in SBP produced by treatment among patients with cerebrovascular disease.
Interaction of Blood Pressure Lowering and Alteplase Dose in Acute Ischemic Stroke: Results of the Enhanced Control of Hypertension and Thrombolysis Stroke Study
Publisher: S. Karger AG
Date: 2019
DOI: 10.1159/000504745
Abstract: b i Objective: /i /b To determine the extent to which the effects of intensive blood pressure (BP) lowering are modified by doses of alteplase in thrombolysis-eligible acute ischemic stroke (AIS) patients. b i Methods: /i /b Prespecified analyses of the Enhanced Control of Hypertension and Thrombolysis Stroke Study for patients enrolled in both arms: (i) low-dose (0.6 mg/kg body weight) or standard-dose (0.9 mg/kg) alteplase and (ii) intensive (target systolic BP [SBP] 130–140 mm Hg) or guideline-recommended (target SBP & #x3c mm Hg) BP management. The primary outcome was functional recovery, measured by a shift in scores on modified Rankin scale at 90 days. The safety outcome was any intracranial hemorrhage (ICH). b i Results: /i /b There were 925 participants (mean age 67 years, 39% female, 77% Asian) randomized to both arms: 242 randomly assigned to guideline/standard-dose (GS) 234 to guideline/low-dose (GL) 227 to intensive/standard-dose (IS) and 222 to intensive/low-dose (IL). Overall, average SBP levels within 24 h were lower in the low-dose compared to standard-dose alteplase group (146 and 144 vs. 151 and 150 mm Hg, for GS and GL vs. IS and IL, respectively, i /i & #x3c 0.0001). There was no heterogeneity of the effects of BP lowering (intensive vs. guideline) on functional recovery between standard-dose (OR 0.81, 95% CI 0.59–1.12) and low-dose alteplase (1.06, 0.77–1.47 i /i = 0.25 for interaction). Similar results were observed for ICH ( i /i = 0.50 for interaction). b i Conclusions: /i /b In thrombolysis-treated patients with predominantly mild-to-moderate severity AIS, intensive BP lowering neither improve functional recovery, either with low- or standard-dose intravenous alteplase, nor beneficially interact with low-dose alteplase in reducing ICH. b i Trial Registration: /i /b The trial is registered with ClinicalTrials.gov (NCT01422616).
Early decompressive hemicraniectomy in thrombolyzed acute ischemic stroke patients from the international ENCHANTED trial
Publisher: Springer Science and Business Media LLC
Date: 13-08-2021
DOI: 10.1038/S41598-021-96087-Z
Abstract: Decompressive hemicraniectomy (DHC) can improve outcomes for patients with severe forms of acute ischemic stroke (AIS), but the evidence is mainly derived from non-thrombolyzed patients. We aimed to determine the characteristics and outcomes of early DHC in thrombolyzed AIS participants of the international Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). Post-hoc analyses of ENCHANTED, an international, partial-factorial, open, blinded outcome-assessed, controlled trial in 4557 thrombolysis-eligible AIS patients randomized to low- versus standard-dose intravenous alteplase (Arm A, n = 2350), intensive versus guideline-recommended blood pressure control (Arm B, n = 1280), or both (Arms A + B, n = 947). Logistic regression models were used to identify baseline variables associated with DHC, with inverse probability of treatment weights employed to eliminate baseline imbalances between those with and without DHC. Logistic regression was also used to determine associations of DHC and clinical outcomes of death/disability, major disability, and death (defined by scores 2–6, 3–5, and 6, respectively, on the modified Rankin scale) at 90 days post-randomization. There were 95 (2.1%) thrombolyzed AIS patients who underwent DHC, who were significantly younger, of non-Asian ethnicity, and more likely to have had prior lipid-lowering treatment and severe neurological impairment from large vessel occlusion than other patients. DHC patients were more likely to receive other management interventions and have poor functional outcomes than non-DHC patients, with no relation to different doses of intravenous alteplase. Compared to other thrombolyzed AIS patients, those who received DHC had a poor prognosis from more severe disease despite intensive in-hospital management.
Trends in five-year survival and risk of recurrent stroke after first-ever stroke in the Perth community stroke study
Publisher: S. Karger AG
Date: 2005
DOI: 10.1159/000083253
Abstract: i Background: /i Few studies provide information on trends in the long-term outcome of stroke. Weaimed to determine trends in survival and recurrent stroke, over 5 years after first-ever stroke, for 2 cohorts of patients enrolled in the Perth Community Stroke Study in 1989–90 and 1995–96. i Methods: /i For 12-month periods beginning February 1989 and February 1995, all in iduals with an acute stroke who were resident in a geographically-defined and representative region of Perth, Western Australia, were registered and followed-up prospectively 5 years after the index event. i Results: /i The 5-year cumulative risk of death was 59% (95% confidence interval (CI) 53%, 65%) and 58% (95% CI 52%, 65%) for the 1989–90 and 1995–96 cohorts, respectively (p = 0.94). The 5-year cumulative risk of first recurrent stroke was 32% (95% CI 25%, 40%) and 23% (95% CI 16%, 30%) for the 1989–90 and 1995–96 cohorts, respectively (p = 0.07). i Conclusions: /i Although no statistically significant improvement occurred in 5-year survival after first-ever stroke in Perth between 1989–90 and 1995–96, there was a statistically nonsignificant trend towards a smaller cumulative risk of recurrent stroke over 5 years after a first-ever stroke. Serial community-based studies of the incidence and outcome of stroke are an important means of monitoring the translation of proven preventive interventions to improvements in population health.
Blood Pressure Management After Intracerebral and Subarachnoid Hemorrhage: The Knowns and Known Unknowns.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2022
DOI: 10.1161/STROKEAHA.121.036139
Abstract: Blood pressure (BP) elevations often complicate the management of intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage, the most serious forms of acute stroke. Despite consensus on potential benefits of BP lowering in the acute phase of intracerebral hemorrhage, controversies persist over the timing, mechanisms, and approaches to treatment. BP control is even more complex for subarachnoid hemorrhage, where there are rationales for both BP lowering and elevation in reducing the risks of rebleeding and delayed cerebral ischemia, respectively. Efforts to disentangle the evidence has involved detailed exploration of in idual patient data from clinical trials through meta-analysis to determine strength and direction of BP change in relation to key outcomes in intracerebral hemorrhage, and which likely also apply to subarachnoid hemorrhage. A wealth of hemodynamic data provides insights into pathophysiological interrelationships of BP and cerebral blood flow. This focused update provides an overview of current evidence, knowledge gaps, and emerging concepts on systemic hemodynamics, cerebral autoregulation and perfusion, to facilitate clinical practice recommendations and future research.
Blood Pressure Management After Endovascular Therapy: An Ongoing Debate
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2021
Blood Pressure Management in Intracranial Hemorrhage: Current Challenges and Opportunities.
Publisher: Springer Science and Business Media LLC
Date: 24-02-2016
DOI: 10.1007/S11936-016-0444-Z
Abstract: Non-traumatic intracranial hemorrhage (i.e. intracerebral hemorrhage [ICH] and subarachnoid hemorrhage [SAH]) are more life threatening and least treatable despite being less common than ischemic stroke. Elevated blood pressure (BP) is a strong predictor of poor outcome in both ICH and SAH. Data from a landmark clinical trial INTERACT 2, wherein 2839 participants enrolled with spontaneous ICH were randomly assigned to receive intensive (target systolic BP <140 mmHg) or guideline recommended BP lowering therapy (target systolic BP <180 mmHg), showed that intensive BP lowering was safe, and more favorable functional outcome and better overall health-related quality of life were seen in survivors in the intensive treatment group. These results contributed to the shift in European and American guidelines towards more aggressive early management of elevated BP in ICH. In contrast, the treatment of BP in SAH is less well defined and more complex. Although there is consensus that hypertension needs to be controlled to prevent rebleeding in the acute setting, induced hypertension in the later stages of SAH has questionable benefits.
Impact of COVID-19 on Patient Behavior to Stroke Symptoms in China
Publisher: S. Karger AG
Date: 2020
DOI: 10.1159/000511394
Psychosocial Interventions for Amphetamine Type Stimulant Use Disorder: An Overview of Systematic Reviews
Publisher: Frontiers Media SA
Date: 17-06-2021
DOI: 10.3389/FPSYT.2021.512076
Abstract: Introduction: Amphetamine-type stimulants (ATS) use is a global concern due to increased usage and the harm to physical, mental, and social well-being. The objective of this overview of systematic reviews is to summarise trial results of psychosocial interventions and describe their efficacy and safety. Methods: We searched seven bibliographic databases to November 2020 for systematic reviews examining ATS misuse treatment by psychosocial interventions. Given the apparent incompleteness of the included reviews, we undertook a supplemental meta-analysis of all eligible primary studies. Results: We included 11 systematic reviews of moderate to high quality and 39 primary studies which assessed the outcomes of psychosocial interventions on people who use ATS. The key findings include: (1) There were conflicting results about the effectiveness of psychosocial interventions among reviews, which may confuse decision-makers in selecting treatment. (2) In the supplemental meta-analysis, relative to usual care (only counselling or self-help materials), membership of a psychological intervention group was associated with an important reduction in drug usage [risk ratio (RR) 0.80, 95% CI: 0.75 to 0.85]. Patients in psychological interventions used injectables substantially less [odds ratio (OR) 0.35, 95% CI: 0.24 to 0.49]. The risk of unsafe sex in the psychosocial intervention group was lower than in the control group (RR 0.49, 95% CI: 0.34 to 0.71). The combination of therapies reduced 1.51 day using drugs in the preceding 30 days (95% CI: −2.36 to −0.67) compared to cognitive behavioural therapy intervention alone. (3) Compared to usual care, cognitive behavioural therapy was less likely to be retained at follow-up (RR 0.89, 95% CI: 0.82 to 0.97 high-quality evidence). However, the additional of contingency management strategy can make an important improvement upon retention (RR 1.42, 95%CI: 1.25 to 1.62). Authors' Conclusions: Integrated models are more effective than a single-treatment strategy. Comprehensive and sustained psychosocial interventions can help to reduce use of ATS and other drugs, risk behaviours and mental disorders, and significantly improve treatment adherence.
Disparities in Secondary Prevention between Stroke and Coronary Heart Disease in China: Cross-Sectional Community-Based Study, 2014–2016
Publisher: S. Karger AG
Date: 08-12-2021
DOI: 10.1159/000519309
Abstract: b i Background: /i /b Health care quality and insurance coverage have improved with economic development in China, but the burden of cardiovascular diseases (CVDs) continues to increase with ongoing gaps in prevention. We aimed to compare the uptake of secondary CVD prevention between stroke and coronary heart disease (CHD) patients in China. b i Methods: /i /b In a cross-sectional community-based survey of 47,841 adults (age ≥45 years) in 7 regions of China between 2014 and 2016, we identified those with a history of stroke or CHD to quantify disparities in conventional secondary CVD prevention strategies in multivariable logistic regression models. b i Results: /i /b There were 4,105 and 1,022 participants with a history of stroke and CHD, respectively. Compared to participants with CHD, those with a history of stroke were significantly less likely to be taking blood-pressure-lowering (39.7% vs. 53%), lipid-lowering (13.7% vs. 36.8%), and antiplatelet (20.8% vs. 50.6%) agents, at least one (48.9% vs. 70.8%) or all 3 recommended medicines (6.1% vs. 24.0%), and were less likely to achieve a lipid-cholesterol target (30.3% vs. 44.0%). Participants with a history of stroke achieved less optimal secondary prevention goals for medication use, either from any (adjusted odds ratio [aOR] 0.54, 95% confidence interval [CI] 0.44–0.66) or all 3 medications (aOR 0.27, 95% CI 0.20–0.36), as well as better blood pressure (aOR 0.81, 95% CI 0.66–0.98) and low-density lipoprotein cholesterol (aOR 0.34, 95% CI 0.27–0.43) levels of control. There were no significant differences in weight, smoking, or physical activity between the groups. b i Conclusion: /i /b Stroke patients had lower use of secondary CVD-preventive medication and achieved lower levels of risk factor control than those of CHD patients in China. Nationwide disease-specific strategies, and better education of participants and health care providers, may narrow these gaps.
Dietary Intake of Key Nutrients and Subarachnoid Hemorrhage: A Population-Based Case-Control Study in Australasia
Publisher: S. Karger AG
Date: 2011
DOI: 10.1159/000324386
Abstract: i Background: /i A healthy, balanced diet can prevent stroke, but little is known about dietary risk factors for subarachnoid hemorrhage (SAH). We aimed to determine the relationship between common dietary habits and risk of SAH. i Methods: /i In a population-based, case-control study of SAH undertaken across 4 Australasian cities, a standardized questionnaire was used to obtain information on the frequency of consumption of 15 common food items and alcohol in incident cases (n = 383) and frequency-matched community controls (n = 473). Logistic regression models were used to estimate the independent effects of these dietary factors, after adjusting for conventional risk factors for SAH. Data are reported with odds ratios (OR) and 95% confidence intervals (CI). i Results: /i The risk of SAH rose with increasing consumption of fat or skin on meat (p trend = 0.04), being highest in those with consumption times weekly compared with no fat or skin on meat (adjusted OR 1.70, 95% CI 1.09–2.66), while use of skim or reduced-fat milk (p trend = 0.01) and fruit (p trend = 0.04) was associated with a reduced risk of SAH compared with rare use. Among people with a history of hypertension, frequently adding salt to food was associated with an increased risk of SAH, irrespective of whether they were (OR 2.58, 95% CI 1.29–5.13) or were not (OR 2.88, 95% CI 1.46–5.70) currently taking antihypertensive treatment. i Conclusions: /i Frequent intake of fat appears to be associated with an increased risk of SAH, particularly in people with hypertension, while frequent use of skim or reduced-fat milk and fruit appears protective for SAH.
Effects of moderate-dose Omega-3 fish oil on cardiovascular risk factors and mood after ischemic stroke: A randomized, controlled trial
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2009
DOI: 10.1161/STROKEAHA.109.555136
Abstract: Background and Purpose— Fish-derived omega-3 fatty acids have long been associated with cardiovascular protection. In this trial, we assessed whether treatment with a guideline-recommended moderate-dose fish oil supplement could improve cardiovascular biomarkers, mood- and health-related quality of life in patients with ischemic stroke. Methods— Patients with CT-confirmed stroke were randomized to 3 g/day encapsulated fish oil containing approximately 1.2 g total omega-3 (0.7 g docosahexaenoic acid 0.3 g eicosapentaenoic acid) or placebo oil (combination palm and soy) taken daily over 12 weeks. Serum triglycerides, total cholesterol and associated lipoproteins, selected inflammatory and hemostatic markers, mood, and health-related quality of life were assessed at baseline and follow-up. The primary outcome was change in triglycerides. Compliance was assessed by capsule count and serum phospholipid omega-3 levels (Australian Clinical Trials Registration: ACTRN12605000207617). Results— One hundred two patients were randomized to fish oil or placebo. Intention-to-treat and per-protocol ( % compliance) analyses showed no significant effect of fish oil treatment on any lipid, inflammatory, hemostatic, or composite mood parameters measured. Adherence to treatment based on pill count was good (89%) reflected by increased serum docosahexanoic acid ( P .001) and eicosapentaenoic acid ( P =0.0006) in the fish oil group. Analysis of oil composition, however, showed some degradation and potentially adverse oxidation products at the end of the study. Conclusions— There was no effect of 12 weeks of treatment with moderate-dose fish oil supplements on cardiovascular biomarkers or mood in patients with ischemic stroke. It is possible that insufficient dose, short duration of treatment, and/or oxidation of the fish oils may have influenced these outcomes.
Family-led rehabilitation after stroke in India: the ATTEND trial, study protocol for a randomized controlled trial
Publisher: Springer Science and Business Media LLC
Date: 07-01-2016
Migraine and risk of subarachnoid haemorrhage: a population-based case-control study
Publisher: Elsevier BV
Date: 06-2005
DOI: 10.1016/J.JOCN.2004.09.009
Abstract: Evidence exists for an association between migraine and ischaemic stroke, but there is uncertainty about whether migraine is a risk factor for subarachnoid haemorrhage (SAH). A multi-centre, population-based, case-control study using cases of first-ever SAH during 1995-98 and matched controls in four study centres in Australia and New Zealand. Self- or proxy-reported history, frequency and characteristics of headaches, classified according to 1988 International Headache Society diagnostic criteria. 206 of 432 (48%) cases and 236 of 473 (50%) controls had a history of headaches. The frequency and characteristics of headaches were similar between the two groups. No association was found in logistic regression analyses for history or frequency of headaches, or migraine headaches. No evidence was found for an association between recurrent headaches and SAH. Such information is important for counselling patients and families about the significance of past and ongoing headaches in relation to this illness.
Applicability of ENCHANTED trial results to current acute ischemic stroke patients eligible for intravenous thrombolysis in England and Wales: Comparison with the Sentinel Stroke National Audit Programme registry.
Publisher: SAGE Publications
Date: 08-04-2019
Abstract: Randomized controlled trials provide high-level evidence, but the necessity to include selected patients may limit the generalisability of their results. Comparisons were made of baseline and outcome data between patients with acute ischemic stroke (AIS) recruited into the alteplase-dose arm of the international, multi-center, Enhanced Control of Hypertension and Thrombolysis Stroke study (ENCHANTED) in the United Kingdom (UK), and alteplase-treated AIS patients registered in the UK Sentinel Stroke National Audit Programme (SSNAP) registry, over the study period June 2012 to October 2015. There were 770 AIS patients (41.2% female mean age 72 years) included in ENCHANTED at sites in England and Wales, which was 19.5% of alteplase-treated AIS patients registered in the SSNAP registry. Trial participants were significantly older, had lower baseline neurological severity, less likely Asian, and had more premorbid symptoms, hypertension and atrial fibrillation. Although ENCHANTED participants had higher rates of symptomatic intracerebral hemorrhage than those in SSNAP, there were no differences in onset-to-treatment time, levels of disability (assessed by the modified Rankin scale) at hospital discharge, and mortality over 90 days between groups. Despite the high level of participation, equipoise over the dose of alteplase among UK clinician investigators favored the inclusion of older, frailer, milder AIS patients in the ENCHANTED trial. Clinical Trial Registration-URL: www.clinicaltrials.gov . Unique identifier: NCT01422616
Surgical Performance Determines Functional Outcome Benefit in the Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) Procedure
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 20-03-2209
Low-Dose versus Standard-Dose Intravenous Alteplase in Acute Ischemic Stroke
Publisher: Massachusetts Medical Society
Date: 16-06-2016
European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage
Publisher: SAGE Publications
Date: 06-2021
DOI: 10.1177/23969873211026998
Abstract: The optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH) remains controversial. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions regarding BP management in acute stroke. The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. Despite several large randomised-controlled clinical trials, quality of evidence is generally low due to inconsistent results of the effect of blood pressure lowering in AIS. We recommend early and modest blood pressure control (avoiding blood pressure levels /105 mm Hg) in AIS patients undergoing reperfusion therapies. There is more high-quality randomised evidence for BP lowering in acute ICH, where intensive blood pressure lowering is recommended rapidly after hospital presentation with the intent to improve recovery by reducing haematoma expansion. These guidelines provide further recommendations on blood pressure thresholds and for specific patient subgroups. There is ongoing uncertainty regarding the most appropriate blood pressure management in AIS and ICH. Future randomised-controlled clinical trials are needed to inform decision making on thresholds, timing and strategy of blood pressure lowering in different acute stroke patient subgroups.
Lenticulostriate artery combined with neuroimaging markers of cerebral small vessel disease differentiate the pathogenesis of recent subcortical infarction.
Publisher: SAGE Publications
Date: 09-02-2021
Abstract: Recent subcortical infarction (RSI) in the lenticulostriate artery (LSA) territory with a non-stenotic middle cerebral artery is a heterogeneous entity. We aimed to investigate the role of LSA combined with neuroimaging markers of cerebral small vessel disease (CSVD) in differentiating the pathogenic subtypes of RSI by whole-brain vessel-wall magnetic resonance imaging (WB-VWI). Fifty-two RSI patients without relevant middle cerebral artery (MCA) stenosis on magnetic resonance angiography were prospectively enrolled. RSI was dichotomized as branch atheromatous disease (BAD a culprit plaque located adjacent to the LSA origin) (n = 34) and CSVD-related lacunar infarction (CSVD-related LI without plaque or plaque located distal to the LSA origin) (n = 18). Logistic regression analysis showed lacunes (odds ratio [OR] 9.68, 95% confidence interval [CI] 1.71–54.72 P = 0.010) and smaller number of LSA branches (OR 0.59, 95% CI 0.36–0.96 P = 0.034) were associated with of BAD, whereas severe deep white matter hyperintensities (DWMH) (OR 0.11, 95% CI 0.02–0.71 P = 0.021) was associated with CSVD-related LI. In conclusion, the LSA branches combined with lacunes and severe DWMH may delineate subtypes of SSI. The WB-VWI technique could be a credible tool for delineating the heterogeneous entity of SSI in the LSA territory.
Edema Extension Distance
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2015
Blood Pressure Management After Intracerebral Hemorrhage.
Publisher: Springer Science and Business Media LLC
Date: 19-10-2015
DOI: 10.1007/S11940-015-0382-1
Abstract: Elevated blood pressure (BP), which presents in approximately 80 % of patients with acute intracerebral hemorrhage (ICH), is associated with increased risk of poor outcome. The Second Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT2) study, a multinational, multicenter, randomized controlled trial published in 2013, demonstrated better functional outcomes with no harm for patients with acute spontaneous ICH within 6 h of onset who received target-driven, early intensive BP lowering (systolic BP target <140 mmHg within 1 h, continued for 7 days) and suggested that greater and faster reduction in BP might enhance the treatment effect by limiting hematoma growth. The trial resulted in revisions of guidelines for acute management of ICH, in which intensive BP lowering in patients with acute ICH is recommended as safe and effective treatment for improving functional outcome. BP lowering is also the only intervention that is proven to reduce the risk of recurrent ICH. Current evidences from several randomized trials, including PROGRESS and SPS3, indicate that long-term strict BP control in patients with ICH is safe and could offer additional benefits in major reduction in risk of recurrent ICH. The latest American Heart Association/American Stroke Association (AHA/ASA) guidelines recommended a target BP of <130/80 mmHg after ICH, but supporting evidence is limited. Randomized controlled trials are needed that focus on strict BP control, initiated early after onset of the disease and continued long-term, to demonstrate effective prevention of recurrent stroke and other major vascular events without additional harms in the ICH population.
Endovascular therapy is effective and safe for patients with severe ischemic stroke: pooled analysis of Interventional Management of Stroke III and Multicenter Randomized Clinical Trial of Endovascular Therapy for Acute Ischemic Stroke in the Netherlands Data (vol 46, pg 3416, 2015)
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2016
Patterns of Use and Discontinuation of Secondary Prevention Medications After Stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 22-10-2020
DOI: 10.1212/WNL.0000000000011083
Abstract: To investigate whether certain patient, acute care, or primary care factors are associated with medication initiation and discontinuation in the community after stroke or TIA. This is a retrospective cohort study using prospective data on adult patients with first-ever acute stroke/TIA from the Australian Stroke Clinical Registry (April 2010 to June 2014), linked with nationwide medication dispensing and Medicare claims data. Medication users were those with ≥1 dispensing in the year postdischarge. Discontinuation was assessed among medication users and defined as having no medication supply for ≥90 days in the year postdischarge. Multivariable competing risks regression, accounting for death during the observation period, was conducted to investigate factors associated with time to medication discontinuation. Among 17,980 registry patients with stroke/TIA, 91.4% were linked to administrative datasets. Of these, 9,817 adults with first-ever stroke/TIA were included (45.4% female, 47.6% aged ≥75 years, and 11.4% intracerebral hemorrhage). While most patients received secondary prevention medications (79.3% antihypertensive, 81.8% antithrombotic, and 82.7% lipid-lowering medication), between one-fifth and one-third discontinued treatment over the subsequent year postdischarge (20.9% antihypertensive, 34.1% antithrombotic, and 28.5% lipid-lowering medications). Prescription at hospital discharge (sub–hazard ratio [SHR] 0.70 95% confidence interval [CI] 0.62–0.79), quarterly contact with a primary care physician (SHR 0.62 95% CI 0.57–0.67), and prescription by a specialist physician (SHR 0.87 95% CI 0.77–0.98) were all inversely associated with antihypertensive discontinuation. Patterns of use of secondary prevention medications after stroke/TIA are not optimal, with many survivors discontinuing treatment within 1 year postdischarge. Improving postdischarge care for patients with stroke/TIA is needed to minimize unwarranted discontinuation.
Left Ventricular Mass and Volume With Telmisartan, Ramipril, or Combination in Patients With Previous Atherosclerotic Events or With Diabetes Mellitus (from the ONgoing Telmisartan Alone and in Combin
Publisher: Elsevier BV
Date: 12-2009
DOI: 10.1016/J.AMJCARD.2009.07.018
Abstract: The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) showed that the angiotensin receptor blocker telmisartan 80 mg was not inferior to the angiotensin-converting enzyme inhibitor ramipril 10 mg, and the combination no more effective than ramipril alone, in decreasing morbidity and mortality in patients with cardiovascular disease or high-risk diabetes. Although therapy targeting angiotensin II is known to decrease left ventricular (LV) mass and volume, the relative influence of angiotensin-converting enzyme inhibitor inhibitors and angiotensin receptor blocker, and their combination, on the heart remains unclear in this population. Magnetic resonance imaging was performed in 287 patients enrolled in ONTARGET, across 8 centers in 6 countries, at randomization and after 2-year treatment (90, 100, and 97 patients in the ramipril, telmisartan, and combination therapy groups, respectively). Baseline patient characteristics showed higher frequencies of coronary artery disease, Asian ethnicity, and use of statins and beta blockers than the main ONTARGET trial. LV mass decreased in all groups (p <0.0001 for each), but there were no significant differences in change in LV mass or volume among groups, except that LV mass index decreased more on combination versus telmisartan (p = 0.04). Key determinants of LV mass decrease were a history of hypertension (p = 0.03), baseline mass (p <0.0001), and decrease in systolic blood pressure (p <0.0001). The best magnetic resonance imaging predictor of composite events was end-systolic volume (p <0.0001). In conclusion, telmisartan and ramipril had similar effects on LV mass and volume, and combination therapy was not more effective, in high-risk patients with cardiovascular disease. These results are consistent with the major outcome findings of the main ONTARGET study.
The short form-12 by telephone as a measure of health-related quality of life after stroke [5]
Publisher: Oxford University Press (OUP)
Date: 11-2000
Barriers from calling ambulance after recognizing stroke differed in adults younger or older than 75 years old in China.
Publisher: Springer Science and Business Media LLC
Date: 12-11-2019
DOI: 10.1186/S12883-019-1480-6
Abstract: As health behavior varies with increasing age, we aimed to examine the potential barriers in calling emergency medical services (EMS) after recognizing a stroke among 40–74- and 75–99-year-old adults. Data were obtained from a cross-sectional community-based study (FAST-RIGHT) that was conducted from January 2017 to May 2017 and involved adults (age ≥ 40 years) across 69 administrative areas in China. A subgroup of residents (153675) who recognized stroke symptoms was analyzed. Multivariable logistic regression models were performed in the 40–74 and 75–99 age groups, separately, to determine the factors associated with wait-and-see behaviors at the onset of a stroke. In the 40–74 and 75–99 age groups, the rates of participants who chose “Self-observation at home” were 3.0% (3912) and 3.5% (738), respectively the rates of “Wait for family, then go to hospital” were 31.7% (42071) and 33.1% (6957), respectively. Rural residence, living with one’s spouse, low income ( 731 US $ per annum), having a single avenue to learn about stroke, and having friends with stroke were factors associated with waiting for one’s family in both groups. However, unlike in the 40–74 age group, sex, number of children, family history, and stroke history did not influence the behaviors at stroke onset in the 75–99 age group. Different barriers from recognizing stroke and calling an ambulance exist in the 40–74 and 75–99 age groups in this specific population. Different strategies that mainly focus on changing the “Wait for family” behavior and emphasize on immediately calling EMS are recommended for both age groups.
Greater Rupture Risk for Familial as Compared to Sporadic Unruptured Intracranial Aneurysms
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2009
DOI: 10.1161/STROKEAHA.108.542571
Abstract: Background and Purpose— The risk of intracranial aneurysm (IA) rupture in asymptomatic members of families who have multiple affected in iduals is not known. Methods— First-degree unaffected relatives of those with a familial history of IA who had a history of smoking or hypertension but no known IA were offered cerebral MR angiography (MRA) and followed yearly as part of a National Institute of Neurological Diseases and Stroke-funded study of familial IA (Familial Intracranial Aneurysm [FIA] Study). Results— A total of 2874 subjects from 542 FIA Study families were enrolled. After study enrollment, MRAs were performed in 548 FIA Study family members with no known history of IA. Of these 548 subjects, 113 subjects (20.6%) had 148 IAs by MRA of whom 5 subjects had IA ≥7 mm. Two subjects with an unruptured IA by MRA/CT angiography (3-mm and 4-mm anterior communicating artery) subsequently had rupture of their IA. This represents an annual rate of 1.2 ruptures per 100 subjects (1.2% per year 95% CI, 0.14% to 4.3% per year). None of the 435 subjects with a negative MRA have had a ruptured IA. Survival curves between the MRA-positive and -negative cohorts were significantly different ( P =0.004). This rupture rate of unruptured IA in the FIA Study cohort of 1.2% per year is approximately 17 times higher than the rupture rate for subjects with an unruptured IA in the International Study of Unruptured Aneurysm Study with a matched distribution of IA size and location 0.069% per year. Conclusions— Small unruptured IAs in patients from FIA Study families may have a higher risk of rupture than sporadic unruptured IAs of similar size, which should be considered in the management of these patients.
Head position in the early phase of acute ischemic stroke: An international survey of current practice
Publisher: Elsevier BV
Date: 07-2015
DOI: 10.1016/J.JSTROKECEREBROVASDIS.2015.03.023
Abstract: Evidence to recommend a specific head position for patients in the early phase of acute ischemic stroke (AIS) is scarce. The aim of this study was to assess current head position practice for AIS patients among physicians from hospitals in different countries. A cross-sectional survey research design was used physicians who are part of a stroke research network were invited to participate by e-mail. Descriptive statistics were used. An invitation to participate was delivered to 298 doctors from 16 countries and 42.9% completed all survey questions. Participant responses were evenly ided in sitting up and lying flat position as the most usual at their hospital: 52.8% (95% confidence interval [CI], 43.7-61.0) of respondents preferred sitting up, whereas 47.2% (95% CI, 38.2-55.5) preferred lying flat 53.9% (95% CI, 45.3-62.5) of participants answered that no written protocol specifying the indicated head position for stroke patients was available at their hospital or department, and 71% (95% CI, 63.2-78.9) recognized being uncertain about the best position for AIS patients. Common practice differs between physicians, and there is a lack of consensus about the best strategy regarding head position for AIS patients in many countries. An opportunity exists for a randomized trial to resolve this uncertainty and develop evidence-based consensus protocols to improve patient management and outcomes.
Stroke Survivors Who Score Below Threshold on Standard Depression Measures May Still Have Negative Cognitions of Concern
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2010
DOI: 10.1161/STROKEAHA.109.571729
Abstract: Background and Purpose— There has been an increase in screening for depression in the physically ill. We explored whether important negative cognitions may be missed by conventional approaches to screening for depression in 2 independently conducted stroke studies with similar methods. Methods— The Auckland Regional Community Stroke (ARCOS) study was a prospective, population-based stroke incidence study conducted in Auckland, New Zealand, for 12 months in 2002 to 2003. The Stroke Outcomes Study was a prospective, hospital cohort study conducted in Leeds and Bradford, United Kingdom, for 33 months in 2002 to 2005. Symptoms of abnormal mood were assessed at 6 months in ARCOS with a single simple question, “Do you often feel sad and depressed?” and the 28-item General Health Questionnaire administered as part of a structured interview and in the Stroke Outcomes Study with the 28-item General Health Questionnaire and a single question about depressed mood taken from the Present State Examination. Results— Mood data were available at 6 months from 770 ARCOS and 492 Stroke Outcomes Study participants. A significant proportion (up to 28%) of people who did not meet study criteria for depression reported important negative cognitions such as hopelessness, worthlessness, or suicidality. People who were older, dependent in activities of daily living, or not partnered were more likely to report negative cognitions. Conclusions— Important negative cognitions, including suicidal thoughts, may be missed when people are screened for depression after stroke. Screening alone is not an adequate substitute for a sensitive exploration of the psychological impact of stroke on the survivor.
Lessons Learned from Whole Exome Sequencing in Multiplex Families Affected by a Complex Genetic Disorder, Intracranial Aneurysm
Publisher: Public Library of Science (PLoS)
Date: 24-03-2015
Quantifying regional variations in components of acute stroke unit (ASU) care in the international HeadPoST study
Publisher: Elsevier BV
Date: 12-2020
Endovascular Therapy Is Effective and Safe for Patients With Severe Ischemic Stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2015
DOI: 10.1161/STROKEAHA.115.011397
Abstract: We assessed the effect of endovascular treatment in acute ischemic stroke patients with severe neurological deficit (National Institutes of Health Stroke Scale score, ≥20) after a prespecified analysis plan. The pooled analysis of the Interventional Management of Stroke III (IMS III) and Multicenter Randomized Clinical Trial of Endovascular Therapy for Acute Ischemic Stroke in the Netherlands (MR CLEAN) trials included participants with an National Institutes of Health Stroke Scale score of ≥20 before intravenous tissue-type plasminogen activator (tPA) treatment (IMS III) or randomization (MR CLEAN) who were treated with intravenous tPA ≤3 hours of stroke onset. Our hypothesis was that participants with severe stroke randomized to endovascular therapy after intravenous tPA would have improved 90-day outcome (distribution of modified Rankin Scale scores), when compared with those who received intravenous tPA alone. Among 342 participants in the pooled analysis (194 from IMS III and 148 from MR CLEAN), an ordinal logistic regression model showed that the endovascular group had superior 90-day outcome compared with the intravenous tPA group (adjusted odds ratio, 1.78 95% confidence interval, 1.20–2.66). In the logistic regression model of the dichotomous outcome (modified Rankin Scale score, 0–2, or functional independence), the endovascular group had superior outcomes (adjusted odds ratio, 1.97 95% confidence interval, 1.09–3.56). Functional independence (modified Rankin Scale score, ≤2) at 90 days was 25% in the endovascular group when compared with 14% in the intravenous tPA group. Endovascular therapy after intravenous tPA within 3 hours of symptom onset improves functional outcome at 90 days after severe ischemic stroke. URL: www.clinicaltrials.gov . Unique identifier: NCT00359424 (IMS III) and ISRCTN10888758 (MR CLEAN).
Low-dose versus standard-dose alteplase in acute ischemic stroke in Asian stroke registries: an individual patient data pooling study
Publisher: SAGE Publications
Date: 21-06-2019
Abstract: To investigate the comparative efficacy and safety of the low-dose versus standard-dose alteplase using real-world acute stroke registry data from Asian countries. In idual participant data were obtained from nine acute stroke registries from China, Japan, Philippines, Singapore, South Korea, and Taiwan between 2005 and 2018. Inverse probability of treatment weight was used to remove baseline imbalances between those receiving low-dose versus standard-dose alteplase. The primary outcome was death or disability defined by modified Rankin Scale scores of 2 to 6 at 90 days. Secondary outcomes were symptomatic intracerebral hemorrhage and death. Generalized linear mixed models with the in idual registry as a random intercept were performed to determine associations of treatment with low-dose alteplase and outcomes. Of the 6250 patients (mean age 66 years, 36% women) included in these analyses, 1610 (24%) were treated with low-dose intravenous alteplase. Clinical outcomes for low-dose alteplase were not significantly different to those for standard-dose alteplase, adjusted odds ratios for death or disability: 1.00 (0.85–1.19) and symptomatic intracerebral hemorrhage 0.87 (0.63–1.19), except for lower death with borderline significance, 0.77 (0.59–1.01). The present analyses of real-world Asian acute stroke registry data suggest that low-dose intravenous alteplase has overall comparable efficacy for functional recovery and greater potential safety in terms of reduced mortality, to standard-dose alteplase for the treatment of acute ischemic stroke.
EvaLuation of early CRRT and beta-blocker InTervention in patients with ECMO (ELITE) trial: study protocol for a 2 × 2 partial factorial randomized controlled trial
Publisher: Springer Science and Business Media LLC
Date: 19-08-2022
DOI: 10.1186/S13063-022-06617-X
Abstract: In critically ill patients requiring extracorporeal membrane oxygenation (ECMO) therapy, early initiation of continuous renal replacement therapy (CRRT) and beta-blockade of catecholamine-induced inotropic effects may improve outcomes. A 2 × 2 partial factorial randomized controlled trial in eligible ECMO patients without a clear indication or contraindication to either intervention is centrally randomly assigned to (A) early or conventional-indicated CRRT and/or (B) beta-blocker or usual care. The primary outcome is all-cause mortality at 30 days for both arms. A total of 496 participants provides 80% power to determine a 20% risk reduction in mortality at 30 days with 5% type I error. This trial will help define the role of early CRRT and beta-blockade in ECMO patients. There have been 89 patients enrolled at 10 hospitals in study A and is ongoing. However, study B was stopped in August 2019 in the absence of any patients being enrolled. ClinicalTrials.gov NCT03549923 . Registered on 8 June 2018. World Health Organization International Clinical Trials Registry Platform (WHO ICTEP) network. The Ethics Committee of Beijing Anzhen Hospital Approval ID is 2018013.
Association of body mass index with mortality and functional outcome after acute ischemic stroke
Publisher: Springer Science and Business Media LLC
Date: 31-05-2017
DOI: 10.1038/S41598-017-02551-0
Abstract: The relation between obesity and stroke outcome has been disputed. This study was aimed to determine the association of body mass index (BMI) with mortality and functional outcome in patients with acute ischemic stroke. Data were from a national, multi-centre, prospective, hospital-based register: the ChinaQUEST (Quality Evaluation of Stroke Care and Treatment) study. Of 4782 acute ischemic stroke patients, 282 were underweight (BMI 18.5 kg/m 2 ), 2306 were normal-weight (BMI 18.5 to 24 kg/m 2 ), 1677 were overweight (BMI 24 to kg/m 2 ) and 517 were obese (BMI ≥ 28 kg/m 2 ). The risks of death at 12 months and death or high dependency at 3 and 12 months in overweight (HR: 0.97, 95% CI: 0.78–1.20 OR: 0.93, 95% CI: 0.80–1.09 OR: 0.95, 95% CI: 0.81–1.12) and obese patients (HR: 1.07, 95% CI: 0.78–1.48 OR: 0.96, 95% CI: 0.75–1.22 OR: 1.06, 95% CI: 0.83–1.35) did not differ from normal-weight patients significantly after adjusting for baseline characteristics. Underweight patients had significantly increased risks of these three outcomes. In ischemic stroke patients, being overweight or obese was not associated with decreased mortality or better functional recovery but being underweight predicted unfavourable outcomes.
Review of the Systolic Blood Pressure Intervention Trial for Hypertension Management: How Low to Go for Patients with Stroke?
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2016
Impact of COVID-2019 on stroke services in China: Survey from the Chinese Stroke Association
Publisher: BMJ
Date: 28-09-2020
Abstract: The COVID-19 pandemic and physical distancing guidelines have compelled stroke practices worldwide to reshape their delivery of care significantly. We aimed to illustrate how the stroke services were interrupted during the pandemic in China. A 61-item questionnaire designed on Wenjuanxing Form was completed by doctors or nurses who were involved in treating patients with stroke from 1 February to 31 March 2020. A total of 415 respondents completed the online survey after informed consent was obtained. Of the respondents, 37.8%, 35.2% and 27.0% were from mild, moderate and severe epidemic areas, respectively. Overall, the proportion of severe impact (reduction %) on the admission of transient ischaemic stroke, acute ischaemic stroke (AIS) and intracerebral haemorrhage (ICH) was 45.0%, 32.0% and 27.5%, respectively. Those numbers were 36.9%, 27.9% and 22.3% 36.5%, 22.1% and 22.6% and 66.4%, 47.5% and 41.1% in mild, moderate and severe epidemic areas, respectively (all p .0001). For AIS, thrombolysis was moderate (20%–50% reduction) or severely impacted ( %), as reported by 54.4% of the respondents, while thrombectomy was 39.3%. These were 44.4%, 26.3% 44.2%, 39.4% and 78.2%, 56.5%, in mild, moderate and severe epidemic areas, respectively (all p .0001). For patients with acute ICH, 39.8% reported the impact was severe or moderate for those eligible for surgery who had surgery. Those numbers were 27.4%, 39.0% and 58.1% in mild, moderate and severe epidemic areas, respectively. For staff resources, about 20% (overall) to 55% (severe epidemic) of the respondents reported moderate or severe impact on the on-duty doctors and nurses. We found a significant reduction of admission for all types of patients with stroke during the pandemic. Patients were less likely to receive appropriate care, for ex le, thrombolysis/thrombectomy, after being admitted to the hospital. Stroke service in severe COVID-19 epidemic areas, for ex le, Wuhan, was much more severely impacted compared with other regions in China.
Anticoagulants for Acute Ischemic Stroke: Cochrane Review
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2022
Diastolic Blood Pressure and Intensive Blood Pressure Control on Cognitive Outcomes: Insights From the SPRINT MIND Trial
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2023
DOI: 10.1161/HYPERTENSIONAHA.122.20112
Abstract: The potential benefits or harms of intensive systolic blood pressure (BP) control on cognitive function and cerebral blood flow in in iduals with low diastolic blood pressure (DBP) remain unclear. We conducted a post hoc analysis of the SPRINT MIND (Systolic Blood Pressure Intervention Trial Memory and Cognition in Decreased Hypertension) that randomly assigned hypertensive participants to an intensive ( mm Hg n=4278) or standard ( mm Hg n=4385) systolic blood pressure target. We evaluated the effects of BP intervention on cognitive outcomes and cerebral blood flow across baseline DBP quartiles. Participants in the intensive group had a lower incidence rate of probable dementia or mild cognitive impairment than those in the standard group, regardless of DBP quartiles. The hazard ratio of intensive versus standard target for probable dementia or mild cognitive impairment was 0.91 (95% CI, 0.73–1.12) in the lowest DBP quartile and 0.70 (95% CI, 0.48–1.02) in the highest DBP quartile, respectively, with an interaction P value of 0.24. Similar results were found for probable dementia (interaction P =0.06) and mild cognitive impairment (interaction P =0.80). The effect of intensive treatment on cerebral blood flow was not modified by baseline DBP either (interaction P =0.25). Even among participants within the lowest DBP quartile, intensive versus standard BP treatment resulted in an increasing trend of annualized change in cerebral blood flow (+0.26 [95% CI, −0.72 to 1.24] mL/[100 g·min]). Intensive BP control did not appear to have a detrimental effect on cognitive outcomes and cerebral perfusion in patients with low baseline DBP. URL: www.clinicaltrials.gov Unique identifier: NCT01206062
Predicting the emergence of malignant brain oedema in acute ischaemic stroke: a prospective multicentre study with development and validation of predictive modelling
Publisher: Elsevier BV
Date: 05-2023
Glucose intolerance and diabetes as risk factors for cognitive impairment in people at high cardiovascular risk: Results from the ONTARGET/TRANSCEND Research Programme
Publisher: Elsevier BV
Date: 03-2009
DOI: 10.1016/J.DIABRES.2008.12.005
Abstract: To assess the cross-sectional associations of the measures of glycemia and cognitive function in subjects at high cardiovascular risk. The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) and concurrent Telmisartan Randomized Assessment Study in ACE intolerant Subjects with Cardiovascular Disease (TRANSCEND) are multi-center, randomized, controlled investigations of different approaches to angiotensin receptor blockade in over 30,000 high CV risk subjects. Baseline data in both trials was used to analyze relationships between measures of glycemic control and cognition. The univariate and multivariate relationships between diabetes status, fasting plasma glucose (FPG), and scores on the Mini-Mental State Examination (MMSE) were assessed. In subjects with diabetes, the mean MMSE score was 0.4 units lower than in those without diabetes (P<0.0001). In all subjects, a 1 mmol/L higher FPG value was associated with a MMSE score that was 0.06 units lower (P<0.0001). The association persisted after adjustment for several cardiovascular risk factors. Dysglycemia is a risk factor for impaired cognitive function in this broadly representative, high-risk study population. Prospective studies can more reliably discern temporal associations, including the effects of glucose lowering in this clinical group.
Effects of a Perindopril-Based Blood Pressure-Lowering Regimen on the Risk of Recurrent Stroke According to Stroke Subtype and Medical History: The PROGRESS Trial
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2004
DOI: 10.1161/01.STR.0000106480.76217.6F
Abstract: Background and Purpose— The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) showed that blood pressure lowering reduced stroke risk in patients with a history of cerebrovascular events. Here, we report the consistency of treatment effects across different stroke subtypes and among major clinical subgroups. Methods— PROGRESS was a randomized, double-blind trial among 6105 people with a prior history of cerebrovascular events. Participants were assigned to active treatment (perindopril for all participants and indapamide for those with neither an indication for nor a contraindication to a diuretic) or matching placebo(s). Results— During a mean of 3.9 years of follow-up, active treatment reduced the absolute rates of ischemic stroke from 10% to 8% (relative risk reduction [RRR], 24% 95% confidence interval [CI], 10 to 35) and the absolute rates of intracerebral hemorrhage from 2% to 1% (RRR, 50% 95% CI, 26 to 67). The relative risk of any stroke during follow-up was reduced by 26% (95% CI, 12 to 38) among patients whose baseline cerebrovascular event was an ischemic stroke and by 49% (95% CI, 18 to 68) among those whose baseline event was an intracerebral hemorrhage. There was no evidence that treatment effects were modified by other drug therapies (antiplatelet or other antihypertensive agents), residual neurological signs, atrial fibrillation, or the time since the last cerebrovascular event. Conclusions— Beneficial effects of a perindopril-based treatment regimen were observed for all stroke types and all major clinical subgroups studied. These data suggest that effective blood pressure–lowering therapy should be routinely considered for all patients with a history of cerebrovascular events.
Atrial fibrillation prevalence, awareness and management in a nationwide survey of adults in China
Publisher: BMJ
Date: 28-01-2021
DOI: 10.1136/HEARTJNL-2020-317915
Abstract: To determine AF prevalence and gaps in atrial fibrillation (AF) awareness and management in China. We conducted a community-based survey of 47 841 adults (age ≥45 years) in seven geographic regions of China between 2014 and 2016. Participants underwent a structured questionnaire, a standard 12-lead ECG, physical examination and blood s ling. AF prevalence, defined by either ECG detection or self-report, was estimated according to s ling weights, non-response and age and sex distribution of the population. We used multivariable logistic regression to estimate associations among sociodemographic, clinical and geographic factors with the AF prevalence, awareness and treatment. The weighted AF prevalence was 1.8% (95% CI 1.7% to 1.9%), but varied from 0.9% to 2.4% across geographical regions and equates to being present in an estimated 7.9 (95% CI 7.4 to 8.4) million people in China. Among men and women, the AF prevalence increased from 0.8% and 0.6% in the age group 45–54 years to 5.4% and 4.9% in the age group ≥75 years, respectively. Proportions of people who were aware of having AF decreased overall from 65.3% in 45–54 year-olds to 53.9% in ≥75 year-olds and varied between sex (men 58.5%, women 68.8%) and residency status (urban 78.3%, rural 35.3%). Only 6.0% of patients with high-risk AF received anticoagulation therapy. AF prevalence is higher than previously reported in China, with low awareness and large treatment gaps. Large-scale efforts are urgently needed to reduce AF adverse consequences.
The Spot Sign and Tranexamic Acid on Preventing ICH Growth – AUStralasia Trial (STOP-AUST): Protocol of a Phase II Randomized, Placebo-Controlled, Double-Blind, Multicenter Trial
Publisher: SAGE Publications
Date: 26-08-2013
DOI: 10.1111/IJS.12132
Abstract: No evidence-based acute therapies exist for intracerebral hemorrhage. Intracerebral hemorrhage growth is an important determinant of patient outcome. Tranexamic acid is known to reduce hemorrhage in other conditions. The study aims to test the hypothesis that intracerebral hemorrhage patients selected with computed tomography angiography contrast extravasation ‘spot sign’ will have lower rates of hematoma growth when treated with intravenous tranexamic acid within 4·5-hours of stroke onset compared with placebo. The Spot sign and Tranexamic acid On Preventing ICH growth – AUStralasia Trial is a multicenter, prospective, 1:1 randomized, double-blind, placebo-controlled, investigator-initiated, academic Phase II trial. Intracerebral hemorrhage patients fulfilling clinical criteria (e.g. Glasgow Coma Scale , intracerebral hemorrhage volume ml, no identified secondary cause of intracerebral hemorrhage, no thrombotic events within the previous 12 months, no planned surgery) and demonstrating contrast extravasation on computed tomography angiography will receive either intravenous tranexamic acid 1 g 10-min bolus followed by 1 g eight-hour infusion or placebo. A second computed tomography will be performed at 24 ± 3 hours to evaluate intracerebral hemorrhage growth and patients followed up for three-months. The primary outcome measure is presence of intracerebral hemorrhage growth by 24 ± 3 hours, defined as either % or ml increase from baseline, and will be adjusted for baseline intracerebral hemorrhage volume. Secondary outcome measures include growth as a continuous measure, thromboembolic events, and the three-month modified Rankin Scale score. This is the first trial to evaluate the efficacy of tranexamic acid in intracerebral hemorrhage patients selected based on an imaging biomarker of high likelihood of hematoma growth. The trial is registered as NCT01702636.
Cognitive function and dementia in hypertension: Epidemiologic and therapeutic aspects
Publisher: Springer Milan
Date: 2012
APOE genotype, ethnicity, and the risk of cerebral hemorrhage.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-02-2008
DOI: 10.1212/01.WNL.0000308819.43401.87
Abstract: The apolipoprotein E (APOE) polymorphism is an established risk factor for intracerebral hemorrhage (ICH) that is related to cerebral amyloid angiopathy in the white population. Among Asian populations, although ICH represents up to one third of all strokes and has high rates of mortality and morbidity, the role of the APOE polymorphism has not been well studied. The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) was a randomized, double-blind, placebo-controlled trial of a blood pressure lowering regimen in subjects with prior cerebrovascular disease. APOE status was determined for 5,671 patients, including 2,148 Asians (38%). During the 3.9 years of follow-up, ICH occurred in 99 patients. Overall, carrying an epsilon 2 or epsilon 4 allele of the APOE polymorphism was associated with an adjusted hazard ratio (HR(a)) of 1.85 (95% CI = 1.24 to 2.76). In Asian patients the risk of ICH for epsilon 2 or epsilon 4 carriers was 2.11 (95% CI = 1.28 to 3.47) and 1.48 (95% CI = 0.76 to 2.87) in Europeans. Carriers of the epsilon 2 or epsilon 4 allele had an increased risk of both incident and recurrent ICH, and both cortical and deep ICH, and most risk estimates were higher in Asians than in Europeans. For both ethnic groups and for subtypes of ICH active treatment more than halved the risk of ICH and the treatment effects were not different in carriers of the epsilon 2 or epsilon 4 allele and in those with the epsilon 3 epsilon 3 genotype. There is a strong association between APOE genotype and the risk of intracerebral hemorrhage (ICH). In Asian patients the role of APOE polymorphisms in ICH is much broader than was previously supposed.
Regional variation in acute stroke care organisation
Publisher: Elsevier BV
Date: 12-2016
DOI: 10.1016/J.JNS.2016.10.026
Abstract: Few studies have assessed regional variation in the organisation of stroke services, particularly health care resourcing, presence of protocols and discharge planning. Our aim was to compare stroke care organisation within middle- (MIC) and high-income country (HIC) hospitals participating in the Head Position in Stroke Trial (HeadPoST). HeadPoST is an on-going international multicenter crossover cluster-randomized trial of 'sitting-up' versus 'lying-flat' head positioning in acute stroke. As part of the start-up phase, one stroke care organisation questionnaire was completed at each hospital. The World Bank gross national income per capita criteria were used for classification. 94 hospitals from 9 countries completed the questionnaire, 51 corresponding to MIC and 43 to HIC. Most participating hospitals had a dedicated stroke care unit/ward, with access to diagnostic services and expert stroke physicians, and offering intravenous thrombolysis. There was no difference for the presence of a dedicated multidisciplinary stroke team, although greater access to a broad spectrum of rehabilitation therapists in HIC compared to MIC hospitals was observed. Significantly more patients arrived within a 4-h window of symptoms onset in HIC hospitals (41 vs. 13% P<0.001), and a significantly higher proportion of acute ischemic stroke patients received intravenous thrombolysis (10 vs. 5% P=0.002) compared to MIC hospitals. Although all hospitals provided advanced care for people with stroke, differences were found in stroke care organisation and treatment. Future multilevel analyses aims to determine the influence of specific organisational factors on patient outcomes.
Worse prognosis in women, compared with men, after thrombolysis: An individual patient data pooling study of Asian acute stroke registries
Publisher: SAGE Publications
Date: 08-07-2021
Abstract: To examine sex differences in disease profiles and short-term outcomes after acute ischemic stroke treated with recombinant tissue plasminogen activator. Eight national and regional stroke registries contributed in idual participant data from mainland China, Japan, Philippines, Singapore, South Korea and Taiwan in 2005–2018. The primary outcome was ordinal-modified Rankin scale at 90 days. Key safety outcome was symptomatic intracerebral hemorrhage (sICH). Of 4453 patients included in the analyses, 1692 (36.3%) were women who were older, more likely to have a more severe neurological deficit, history of hypertension and atrial fibrillation, and a cardioembolic stroke compared to men. Women were more likely than men to have unfavorable shift of modified Rankin scale (fully adjusted odds ratio) (women vs. men) 1.14, 95% confidence interval 1.02–1.28). There was no significant sex difference for death 1.05 (0.84–1.31) or sICH (1.17, 0.89–1.54). Women were more likely to have unfavorable functional outcome with increasing age (P = 0.022 for interaction). In the age groups 70–80 and ≥80 years, women had a worse functional outcome compared to men (1.22, 1.02–1.47 and 1.43, and 1.06–1.92, respectively). In this pooled data from Asian acute stroke registries, women had poorer prognosis than men after receiving recombinant tissue plasminogen activator for acute ischemic stroke, which worsened with age. Women older than 70 appear to have a worse outcome than men which could be explained by greater stroke severity, more AF, and cardioembolic stroke.
Life events and risk of subarachnoid hemorrhage: The Australasian cooperative research on subarachnoid hemorrhage study (ACROSS)
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2010
DOI: 10.1161/STROKEAHA.109.575282
Abstract: Background and Purpose— Because little evidence exists and the topic often raises concerns, we aimed to determine the relationship between life events and subarachnoid hemorrhage (SAH) in a population-based case–control setting. Methods— In 388 SAH incident cases and 473 frequency-matched community SAH-free control subjects, information on the occurrence of 12 types of adverse life events in the preceding 1 and 2 to 12 months was obtained by interview using a questionnaire based on the Social Behavior Assessment Schedule. Analyses involved logistic regression models with adjustment for confounding variables. Results— Among 12 life events, only 2 (“financial/legal problems” and “other”) in the past month were marginally associated with SAH ( P =0.04 and 0.03, respectively), whereas “physical attack/assault” and “injury/disease of a relative/friend et” during the past 2 to 12 months also showed similarly marginally significant and imprecise associations (inversely) with SAH. There were no clear associations between multiple life events and SAH for both the prior month and 2 to 12 months (both P .4). Conclusions— Life events are unlikely to have appreciable effects on the risk of SAH.
Cerebellar Infarction and Factors Associated with Delayed Presentation and Misdiagnosis
Publisher: S. Karger AG
Date: 2016
DOI: 10.1159/000448899
Abstract: b i Background and Purpose: /i /b The diagnosis of cerebellar infarction (CBI) is often challenging due to non-specific or subtle presenting symptoms and signs. We aimed to determine whether a common syndromic cluster of symptoms, signs or vascular risk factors were associated with delayed presentation or misdiagnosis to an Emergency Department (ED). The degree of misdiagnosis between ED and neurology physicians and the influence of delayed presentation or misdiagnosis on outcome were also investigated. b i Methods: /i /b A prospective study of CBI patients at a large tertiary-referral hospital with a comprehensive stroke service. Data are reported with OR and 95% CIs. b i Results: /i /b Of 115 consecutive CBI patients (mean age ± SD 66 ± 14 years, 51% male), infarction was isolated to the cerebellum in 46% the remainder had additional vascular territory involvement (‘mixed CBI'). Most patients (n = 79, 69%) had a mild stroke (National Institute of Health Stroke Scale score ≤4), and tended to present late to ED ( .5 h p = 0.05). Dysarthria (OR 3.9, 95% CI 1.6-9.6, p = 0.003) and prior history of atrial fibrillation (AF OR 3.0, 95% CI 1.02-9.1, p = 0.047) predicted early presentation ( .5 h in 52%). Neurological signs (as determined by neurology physicians) were more commonly absent in patients with isolated CBI (OR 4.0, 95% CI 1.2-13.3, p = 0.03) who were also less likely to receive acute stroke therapy (p = 0.03). ED physicians detected fewer neurological signs than neurology physicians (mean 1 vs. 2 signs, p 0.001), and 34% of CBI patients were misdiagnosed, with peripheral vestibulopathy being the most common alternative diagnosis. Nausea and vomiting (OR 2.3, 95% CI 1.01-5.5, p = 0.046), absence of neurological signs as determined by ED physicians (OR 3.5, 95% CI 1.5-8.0, p = 0.003) and isolated CBI (OR 2.2, 95% CI 1.01-4.8, p = 0.047) correlated with misdiagnosis. Vascular territory involvement did not correlate with time to presentation or misdiagnosis. At 3 months, 65% of patients were functionally independent (modified Rankin Scale (mRS) score 0-2). History of hypertension (p = 0.008), AF (p = 0.012), mixed CBI (p = 0.004) and in-hospital stroke-related complications (p 0.001) were associated with patients having a poor outcome (mRS ≥3). At 3 months, mortality was 16%, and AF was the only predictor of death (OR 3.2, 95% CI 1.1-8.9, p = 0.03). Late presentation to ED and misdiagnosis did not significantly influence 3-month functional outcome. b i Conclusions: /i /b Late ED presentation and misdiagnosis are common for CBI. Timely diagnosis of CBI may increase opportunity for acute stroke therapies and reduce risk of stroke-related complications.
Effects of visit-to-visit variability in systolic blood pressure on macrovascular and microvascular complications in patients with type 2 diabetes mellitus
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 17-09-2013
DOI: 10.1161/CIRCULATIONAHA.113.002717
Abstract: Recent evidence suggests that visit-to-visit variability in systolic blood pressure (SBP) and maximum SBP are predictors of cardiovascular disease. However, it remains uncertain whether these parameters predict the risks of macrovascular and microvascular complications in patients with type 2 diabetes mellitus. The Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) was a factorial randomized controlled trial of blood pressure lowering and blood glucose control in patients with type 2 diabetes mellitus. The present analysis included 8811 patients without major macrovascular and microvascular events or death during the first 24 months after randomization. SBP variability (defined as standard deviation) and maximum SBP were determined during the first 24 months after randomization. During a median 2.4 years of follow-up from the 24-month visit, 407 major macrovascular (myocardial infarction, stroke, or cardiovascular death) and 476 microvascular (new or worsening nephropathy or retinopathy) events were observed. The association of major macrovascular and microvascular events with SBP variability was continuous even after adjustment for mean SBP and other confounding factors (both P .05 for trend). Hazard ratios (95% confidence intervals) for the highest tenth of SBP variability were 1.54 (0.99–2.39) for macrovascular events and 1.84 (1.19–2.84) for microvascular events in comparison with the lowest tenth. For maximum SBP, hazard ratios (95% confidence intervals) for the highest tenth were 3.64 (1.73–7.66) and 2.18 (1.04–4.58), respectively. Visit-to-visit variability in SBP and maximum SBP were independent risk factors for macrovascular and microvascular complications in type 2 diabetes mellitus. URL: www.clinicaltrials.gov . Unique Identifier: NCT00145925.
The Neglected Burden of Stroke in Sub-Saharan Africa
Publisher: SAGE Publications
Date: 11-2006
DOI: 10.1111/J.1747-4949.2006.00064.X
Abstract: The looming epidemic of stroke and other chronic non-communicable diseases associated with lifestyle and demographic transitions occurring all over the world is increasingly being acknowledged. However, the significance of these trends in the relatively young populations of the countries comprising Sub-Saharan Africa (SSA) is less certain and considerably overshadowed by attention given to the impact of human immunodeficiency virus and other infectious diseases. We undertook a literature review of the burden of stroke in SSA and provide recommendations for future research. Despite the paucity of high quality studies, the mostly hospital-based data and limited community surveys indicate there to be high and increasing rates of stroke affecting people at much younger ages in SSA than in developed countries. In general, awareness, diagnosis and management of stroke are poor, and the associated case fatality and residual disability are high. As elsewhere, elevated blood pressure is the major determinant of stroke but there are also high rates of strokes related to the complications of rheumatic heart disease and other infections. Given high attributable risks exposures in association with rapid ageing and urbanisation in SSA, the future is not bright. Population-based incidence studies are urgently needed to map the profile and outcome of stroke. Such data would provide the necessary evidence base to improve prevention and treatments for stroke alongside current efforts to bring infectious diseases under control in SSA.
Early Blood Pressure Lowering Does Not Reduce Growth of Intraventricular Hemorrhage following Acute Intracerebral Hemorrhage: Results of the INTERACT Studies
Publisher: S. Karger AG
Date: 08-09-2016
DOI: 10.1159/000448897
Abstract: b i Background: /i /b Intraventricular hemorrhage (IVH) extension is common following acute intracerebral hemorrhage (ICH) and is associated with poor prognosis. b i Aim: /i /b To determine whether intensive blood pressure (BP)-lowering therapy reduces IVH growth. b i Methods: /i /b Pooled analyses of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials (INTERACT1 and INTERACT2) computed tomography (CT) substudies multicenter, open, controlled, randomized trials of patients with acute spontaneous ICH and elevated systolic BP, randomly assigned to intensive ( mm Hg) or guideline-based ( mm Hg) BP management. Participants had blinded central analyses of baseline and 24-hour CT. Association of BP lowering to IVH growth was assessed in analysis of covariance. b i Results: /i /b There was no significant difference in adjusted mean IVH growth following intensive (n = 228) compared to guideline-recommended (n = 228) BP treatment (1.6 versus 2.2 ml, respectively p = 0.56). Adjusted mean IVH growth was nonsignificantly greater in patients with a mean achieved systolic BP ≥160 mm Hg over 24 h (3.94 ml p trend = 0.26). b i Conclusions: /i /b Early intensive BP-lowering treatment had no clear effect on IVH in acute ICH.
Dysphagia screening and risks of pneumonia and adverse outcomes after acute stroke: An international multicenter study
Publisher: SAGE Publications
Date: 21-06-2020
Abstract: Dysphagia is associated with aspiration pneumonia after stroke. Data are limited on the influences of dysphagia screen and assessment in clinical practice. To determine associations between a “brief” screen and “detailed” assessment of dysphagia on clinical outcomes in acute stroke patients. A prospective cohort study analyzed retrospectively using data from a multicenter, cluster cross-over, randomized controlled trial (Head Positioning in Acute Stroke Trial [HeadPoST]) from 114 hospitals in nine countries. HeadPoST included 11,093 acute stroke patients randomized to lying-flat or sitting-up head positioning. Herein, we report predefined secondary analyses of the association of dysphagia screening and assessment and clinical outcomes of pneumonia and death or disability (modified Rankin scale 3–6) at 90 days. Overall, 8784 (79.2%) and 3917 (35.3%) patients were screened and assessed for dysphagia, respectively, but the frequency and timing for each varied widely across regions. Neither use of a screen nor an assessment for dysphagia was associated with the outcomes, but their results were compared to “screen-pass” patients, those who failed had higher risks of pneumonia (adjusted odds ratio [aOR] = 3.00, 95% confidence interval [CI] = 2.18–4.10) and death or disability (aOR = 1.66, 95% CI = 1.41–1.95). Similar results were evidence for the results of an assessment for dysphagia. Subsequent feeding restrictions were related to higher risk of pneumonia in patients failed dysphagia screen or assessment (aOR = 4.06, 95% CI = 1.72–9.54). Failing a dysphagia screen is associated with increased risks of pneumonia and poor clinical outcome after acute stroke. Further studies concentrate on determining the effective subsequent feeding actions are needed to improve patient outcomes.
Study protocol for development and validation of a single tool to assess risks of stroke, diabetes mellitus, myocardial infarction and dementia: DemNCD-Risk
Publisher: BMJ
Date: 09-2023
Pharmaceutical interventions for emotionalism after stroke
Publisher: John Wiley & Sons, Ltd
Date: 19-04-2004
The Effect of Frailty on the Efficacy and Safety of Intensive Blood Pressure Control: A Post Hoc Analysis of the SPRINT Trial
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 15-08-2023
DOI: 10.1161/CIRCULATIONAHA.123.064003
Abstract: Frailty is associated with an increased risk of all-cause death and cardiovascular events. However, it is uncertain whether frailty modifies the efficacy and safety of intensive blood pressure control. Data from SPRINT (Systolic Blood Pressure Intervention Trial) were used to construct a frailty index. Subgroup differences in intensive blood pressure control treatment effects and safety outcomes were measured on a relative and an absolute scale in patients with and without frailty (defined as a frailty index .21) using Cox proportional hazard models and generalized linear models, respectively. The primary outcome was a composite of myocardial infarction, acute coronary syndrome without myocardial infarction, stroke, heart failure, and cardiovascular death. A total of 9306 patients (mean age, 67.9±9.4 years), 2560 (26.7%) of whom had frailty, were included in our study. Over a median follow-up of 3.22 years, 561 primary outcomes were observed. Patients with frailty had a significantly higher risk of primary outcome in both the intensive and standard blood pressure control arms (adjusted hazard ratio, 2.10 [95% CI, 1.59–2.77] and 1.85 [95% CI, 1.46–2.35], respectively). Intensive treatment effects on primary and secondary outcomes were not significantly different on a relative scale (except for cardiovascular death [hazard ratio in patients with and without frailty, 0.91 (95% CI, 0.52–1.60) versus 0.30 (95% CI, 0.16–0.59), respectively P interaction =0.01]) or absolute scale. There was no significant interaction between frailty and risks for serious adverse events with intensive treatment. Frailty status was a marker of high cardiovascular risk. Patients with frailty benefit similarly to other patients from intensive blood pressure control without an increased risk of serious adverse events.
Association of 3 Different Antihypertensive Medications With Hip and Pelvic Fracture Risk in Older Adults
Publisher: American Medical Association (AMA)
Date: 2017
DOI: 10.1001/JAMAINTERNMED.2016.6821
Abstract: On the basis of observational studies, the use of thiazide diuretics for the treatment of hypertension is associated with reduced fracture risk compared with nonuse. Data from randomized clinical trials are lacking. To examine whether the use of thiazide diuretics for the treatment of hypertension is associated with reduced fracture risk compared with nonuse. Using Veterans Affairs and Medicare claims data, this study examined hip and pelvic fracture hospitalizations in Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial participants randomized to first-step therapy with a thiazide-type diuretic (chlorthalidone), a calcium channel blocker (amlodipine besylate), or an angiotensin-converting enzyme inhibitor (lisinopril). Recruitment was from February 1994 to January 1998 in-trial follow-up ended in March 2002. The mean follow-up was 4.9 years. Posttrial follow-up was conducted through the end of 2006, using passive surveillance via national databases. For this secondary analysis, which used an intention-to-treat approach, data were analyzed from February 1, 1994, through December 31, 2006. Hip and pelvic fracture hospitalizations. A total of 22 180 participants (mean [SD] age, 70.4 [6.7] years 43.0% female and 49.9% white non-Hispanic, 31.2% African American, and 19.1% other ethnic groups) were followed for up to 8 years (mean [SD], 4.9 [1.5] years) during masked therapy. After trial completion, 16 622 participants for whom claims data were available were followed for up to 5 additional years (mean [SD] total follow-up, 7.8 [3.1] years). During the trial, 338 fractures occurred. Participants randomized to receive chlorthalidone vs amlodipine or lisinopril had a lower risk of fracture on adjusted analyses (hazards ratio [HR], 0.79 95% CI, 0.63-0.98 P = .04). Risk of fracture was significantly lower in participants randomized to receive chlorthalidone vs lisinopril (HR, 0.75 95% CI, 0.58-0.98 P = .04) but not significantly different compared with those randomized to receive amlodipine (HR, 0.82 95% CI, 0.63-1.08 P = .17). During the entire trial and posttrial period of follow-up, the cumulative incidence of fractures was nonsignificantly lower in participants randomized to receive chlorthalidone vs lisinopril or amlodipine (HR, 0.87 95% CI, 0.74-1.03 P = .10) and vs each medication separately. In sensitivity analyses, when 1 year after randomization was used as the baseline (to allow for the effects of medications on bone to take effect), similar results were obtained for in-trial and in-trial plus posttrial follow-up. These findings from a large randomized clinical trial provide evidence of a beneficial effect of thiazide-type diuretic therapy in reducing hip and pelvic fracture risk compared with treatment with other antihypertensive medications. clinicaltrials.gov Identifier: NCT00000542.
Effects of intensive blood pressure lowering on cerebral ischaemia in thrombolysed patients: insights from the ENCHANTED trial
Publisher: Elsevier BV
Date: 03-2023
Suboptimal awareness and control of hypertension increases the risk of subarachnoid hemorrhage in the community: results from the ACROSS
Publisher: Informa UK Limited
Date: 12-2013
Frequency, determinants, and effects of early seizures after thrombolysis for acute ischemic stroke: The ENCHANTED trial
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 19-07-2017
DOI: 10.1212/CPJ.0000000000000384
Abstract: Seizures after ischemic stroke have not been well-studied. We aim to determine the frequency, determinants, and significance of early seizures after thrombolysis for acute ischemic stroke. Data are from the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED), an international, multicenter, randomized controlled trial where patients with acute ischemic stroke were randomized to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) IV alteplase. The protocol prespecified prospective data collection on in-hospital seizures over 7 days postrandomization. Logistic regression models were used to determine variables associated with seizures and their significance on poor outcomes of death or disability (modified Rankin scale scores 3–6), symptomatic intracerebral hemorrhage (sICH), and European Quality of Life 5-Dimensions questionnaire [EQ-5D] over 90 days. Data were available for 3,139 acute ischemic stroke participants, of whom 42 (1.3%) had seizures at a median 22.7 hours after the onset of symptoms. Baseline variables associated with seizures were male sex (odds ratio [OR] 2.19, 95% confidence interval [CI] 1.07–4.50), severe neurologic impairment (NIH Stroke Scale score ≥10 OR 2.16, 95% CI 1.06–4.40), and fever (OR 4.55, 95% CI 2.37–8.71). Seizures independently predicted poor recovery: death or major disability (OR 2.88, 95% CI 1.28–6.47), unfavorable ordinal shift of mRS scores (OR 1.94, 95% CI 1.10–3.39), and lower than median EQ-5D health utility index score (OR 3.50, 95% CI 1.37–8.91). There was no association of seizures with sICH in adjusted analysis. In thrombolysis-treated patients with acute ischemic stroke, seizures are uncommon, occur early, and predict poor recovery. NCT01422616.
Randomized clinical trials of cardiovascular disease in obstructive sleep apnea: understanding and overcoming bias
Publisher: Oxford University Press (OUP)
Date: 08-03-2021
Familial Intracranial Aneurysms
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2013
DOI: 10.1161/STROKEAHA.112.667261
Abstract: Previous studies have suggested that family members with intracranial aneurysms (IAs) often harbor IAs in similar anatomic locations. IA location is important because of its association with rupture. We tested the hypothesis that anatomic susceptibility to IA location exists using a family-based IA study. We identified all affected probands and first-degree relatives (FDRs) with a definite or probable phenotype in each family. We stratified each IA of the probands by major arterial territory and calculated each family’s proband-FDR territory concordance and overall contribution to the concordance analysis. We then matched each family unit to an unrelated family unit selected randomly with replacement and performed 1001 simulations. The median concordance proportions, odds ratios (ORs), and P values from the 1001 logistic regression analyses were used to represent the final results of the analysis. There were 323 family units available for analysis, including 323 probands and 448 FDRs, with a total of 1176 IAs. IA territorial concordance was higher in the internal carotid artery (55.4% versus 45.6% OR, 1.54 [1.04–2.27] P =0.032), middle cerebral artery (45.8% versus 30.5% OR, 1.99 [1.22–3.22] P =0.006), and vertebrobasilar system (26.6% versus 11.3% OR, 2.90 [1.05–8.24], P =0.04) distributions in the true family compared with the comparison family. Concordance was also higher when any location was considered (53.0% versus 40.7% OR, 1.82 [1.34–2.46] P .001). In a highly enriched s le with familial predisposition to IA development, we found that IA territorial concordance was higher when probands were compared with their own affected FDRs than with comparison FDRs, which suggests that anatomic vulnerability to IA formation exists. Future studies of IA genetics should consider stratifying cases by IA location.
Head Positioning in Acute Stroke
Publisher: Massachusetts Medical Society
Date: 14-09-2017
DOI: 10.1056/NEJMC1709517
Stroke care and collaborative academic research in Latin America
Publisher: Instituto Nacional de Salud Publica
Date: 13-06-2022
DOI: 10.21149/12803
Abstract: Objective. A narrative overview of regional academic research collaborations to address the increasing burden and gaps in care for patients at risk of, and who suffer from, stroke in Latin America (LA). Materials and methods. A summary of experiences and knowledge of the local situation is presented. No systematic literature review was performed. Results. The rapidly increasing burden of stroke poses immense challenges in LA, where prevention and management strategies are highly uneven and inadequate. Clinical research is increasing through various academic consortia and networks formed to overcome structural, funding and skill barriers. However, strengthening the ability to generate, analyze and interpret randomized evidence is central to further develop effective therapies and healthcare systems in LA. Conclusions. Regional networks foster the conduct of multicenter studies –particularly randomized controlled trials–, even in resource-poor regions. They also contribute to the external validity of international studies and strengthen systems of care, clinical skills, critical thinking, and international knowledge exchange.
A step forward in resolving uncertainties over blood-pressure management in acute stroke
Publisher: Elsevier BV
Date: 08-2010
Pathways to enhancing the quality of stroke care through national data monitoring systems for hospitals
Publisher: AMPCo
Date: 11-2013
DOI: 10.5694/MJA12.11821
Predictors of depression after stroke: A systematic review of observational studies
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2005
DOI: 10.1161/01.STR.0000183622.75135.A4
Abstract: Background and Purpose— Although depression is common after stroke, there is uncertainty over its etiology and risk factors, which complicates management. Knowledge of the predictors of depression associated with stroke may allow for the better targeting of therapy, both prevention and treatment. Methods— We undertook a systematic review of all published, nonexperimental, population-, hospital-, and rehabilitation-based stroke studies (to June 2004) with prospective, consecutive patient recruitment undertaken to identify variables associated with depressive symptoms (or “illness”) after stroke. Assessments were made of the quality of studies including the validity of prognostic models. Results— Data were available from 3 population-based studies including 492 patients, 8 hospital-based studies including 15 272 patients, and 9 rehabilitation-based studies including 2170 patients. Physical disability, stroke severity and cognitive impairment were consistently associated with depression. In addition to the common problem of selection bias, major limitations of these studies included variable selection and poor statistical quality and reporting small s le sizes meant that only a limited range of variables were analyzed in multivariate models. Conclusions— There is a paucity of well-designed studies of sufficient size to allow stable multivariate predictive models of depression after stroke to be developed. Other than showing that depression is associated with more severe strokes, current evidence does not allow for ready identification of patients most at risk of developing this important complication of stroke.
Validation of a clinical classification for subtypes of acute cerebral infarction.
Publisher: BMJ
Date: 10-1994
Abstract: The validity of a clinical classification system was assessed for subtypes of cerebral infarction for use in clinical trials of putative stroke therapies and clinical decision making in a population based stroke register (n = 536) compiled in Perth, Western Australia in 1989-90. The Perth Community Stroke Project (PCSS) used definitions and methodology similar to the Oxfordshire Community Stroke Project (OCSP) where the classification system was developed. In the PCSS, 421 cases of cerebral infarction and primary intracerebral haemorrhage (PICH), confirmed by brain imaging or necropsy, were classified into the subtypes total anterior circulation syndrome (TACS), partial anterior circulation syndrome (PACS), lacunar syndrome (LACS), and posterior circulation syndrome (POCS). In this relatively unselected population, relying exclusively on LACS for a diagnosis of PICH had a very low sensitivity (6%) and positive predictive value (3%). Comparison of the frequencies and outcomes (at one year after the onset of symptoms) for each subgroup of first ever cerebral infarction in the PCSS (n = 248) with the OCSP (n = 543) registers showed uniformity only for LACI. For ex le, there were 27% of cases of TACI in the PCSS compared with 17% in the OCSP (difference = 10% 95% confidence interval (95% CI) 4% to 16%) and 15% of cases in the PCSS compared with 24% in the OCSP were POCI (difference = 9% 95% CI 3% to 15%). Case fatalities and long-term handicap across the subgroups were not significantly different between studies, but the frequencies of recurrent stroke were significantly greater for POCI in the OCSP compared with the PCSS. Although this classification system defines subtypes of stroke with different outcomes, simple clinical measures-level of consciousness, paresis, disability, and incontinence at onset-are more powerful predictors of death or dependency at one year. It is concluded that simple clinical measures that reflect the severity of the neurological deficit should complement this classification system in clinical trials and practice.
Protocol and Pilot Data for Establishing the Australian Stroke Clinical Registry
Publisher: SAGE Publications
Date: 06-2010
DOI: 10.1111/J.1747-4949.2010.00430.X
Abstract: Disease registries assist with clinical practice improvement. The Australian Stroke Clinical Registry aims to provide national, prospective, systematic data on processes and outcomes for stroke. We describe the methods of establishment and initial experience of operation. Australian Stroke Clinical Registry conforms to new national operating principles and technical standards for clinical quality registers. Features include: online data capture from acute public and private hospital sites opt-out consent expert consensus agreed core minimum dataset with standard definitions outcomes assessed at 3 months post-stroke formal governance oversight and formative evaluations for improvements. Qualitative feedback from sites indicates that the web-tool is simple to use and the user manuals, data dictionary, and training are appropriate. However, sites desire automated data-entry methods for routine demography variables and the opt-out consent protocol has sometimes been problematic. Data from 204 patients (median age 71 years, 54% males, 60% Australian) were collected from four pilot hospitals from June to October 2009 (mean, 50 cases per month) including ischaemic stroke (in 72%), intracerebral haemorrhage (16%), transient ischaemic attack (9%), and undetermined (3%), with only one case opting out. Australian Stroke Clinical Registry has been well established, but further refinements and broad roll-out are required before realising its potential of improving patient care through clinician feedback and allowance of local, national, and international comparative data.
Early predictors of remission in newly diagnosed epilepsy: a systematic approach to reviewing prognostic factor studies
Publisher: Informa UK Limited
Date: 23-10-2013
Sex differences in blood pressure after stroke: a systematic review and meta-analysis.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2019
Safety and efficacy of fluoxetine on functional outcome after acute stroke (AFFINITY): a randomised, double-blind, placebo-controlled trial
Publisher: Elsevier BV
Date: 08-2020
Unraveling Blood Pressure Outcome Relationships: Further Insights From the Prehospital Phase
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2022
Process Evaluation of an Implementation Trial: Design, Rationale, and Early Lessons Learnt From an International Cluster Clinical Trial in Intracerebral Hemorrhage
Publisher: Frontiers Media SA
Date: 15-06-2022
Abstract: The third INTEnsive care bundle with blood pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT3) is an ongoing, international, multicenter, stepped-wedge cluster, prospective, randomized, open, blinded endpoint assessed trial evaluating the effectiveness of a quality improvement “care bundle” for the management of patients with acute spontaneous intracerebral hemorrhage (ICH) in low- and middle-income countries (LMICs). An embedded process evaluation aims to explore the uptake and implementation of the intervention, and understand the context and stakeholder perspectives, for interpreting the trial outcomes. The design was informed by Normalization Process Theory and the UK Medical Research Council process evaluation guidance. Mixed methods are used to evaluate the implementation outcomes of fidelity, reach, dose, acceptability, appropriateness, adoption, sustainability, and relevant contextual factors and mechanisms affecting delivery of the care bundle. Semi-structured interviews and non-participant observations are conducted with the primary implementers (physicians and nurses) and patients/carers to explore how the care bundle was integrated into routine care. Focus group discussions are conducted with investigators and project operational staff to understand challenges and possible solutions in the organization of the trial. Data from observational records, surveys, routine monitoring data, field notes and case report forms, inform contextual factors, and adoption of the intervention. Purposive s ling of sites according to pre-specified criteria is used to achieve s le representativeness. Implementation outcomes, and relevant barriers and facilitators to integrating the care bundle into routine practice, will be reported after completion of the process evaluation. The embedded process evaluation will aid understanding of the causal mechanisms between care bundle elements and clinical outcomes within complex health systems across erse LMIC settings. The INTERACT3 study is registered at ClinicalTrials.gov (NCT03209258).
Sydney epilepsy incidence study to measure illness consequences: The SESIMIC observational epilepsy study protocol
Publisher: Springer Science and Business Media LLC
Date: 09-01-2011
Affected twins in the familial intracranial aneurysm study
Publisher: S. Karger AG
Date: 2015
DOI: 10.1159/000369961
Abstract: b i Background and Purpose: /i /b Very few cases of intracranial aneurysms (IAs) in twins have been reported. Previous work has suggested that vulnerability to IA formation is heritable. Twin studies provide an opportunity to evaluate the impact of genetics on IA characteristics, including IA location. We therefore sought to examine IA location concordance, multiplicity, and rupture status within affected twin-pairs. b i Methods: /i /b The Familial Intracranial Aneurysm study was a multicenter study whose goal was to identify genetic and other risk factors for formation and rupture of IAs. The study required at least three affected family members or an affected sibling pair for inclusion. Subjects with fusiform aneurysms, an IA associated with an AVM, or a family history of conditions known to predispose to IA formation, such as polycystic kidney disease, Ehlers-Danlos syndrome, Marfan syndrome, fibromuscular dysplasia, or moyamoya syndrome were excluded. Twin-pairs were identified by birth date and were classified as monozygotic (MZ) or dizygotic (DZ) through DNA marker genotypes. In addition to zygosity, we evaluated twin-pairs by smoking status, major arterial territory of IAs, and rupture status. Location concordance was defined as the presence of an IA in the same arterial distribution (ICA, MCA, ACA, and vertebrobasilar), irrespective of laterality, in both members of a twin-pair. The Fisher exact test was used for comparisons between MZ and DZ twin-pairs. b i Results: /i /b A total of 16 affected twin-pairs were identified. Location concordance was observed in 8 of 11 MZ twin-pairs but in only 1 of 5 DZ twin-pairs (p = 0.08). Three MZ subjects had unknown IA locations and comprised the three instances of MZ discordance. Six of the 11 MZ twin-pairs and none of the 5 DZ twin-pairs had IAs in the ICA distribution (p = 0.03). Multiple IAs were observed in 11 of 22 MZ and 5 of 10 DZ twin-pairs. Thirteen (13) of the 32 subjects had an IA rupture, including 10 of 22 MZ twins. b i Conclusions: /i /b We found that arterial location concordance was greater in MZ than DZ twins, which suggests a genetic influence upon aneurysm location. The 16 twin-pairs in the present study are nearly the total of affected twin-pairs that have been reported in the literature to date. Further studies are needed to determine the impact of genetics in the formation and rupture of IAs.
Influence of Including Patients with Premorbid Disability in Acute Stroke Trials: The HeadPoST Experience
Publisher: S. Karger AG
Date: 2021
DOI: 10.1159/000512608
Abstract: b i Background: /i /b Patients with premorbid functional impairment are generally excluded from acute stroke trials. We aimed to determine the impact of including such patients in the Head Positioning in acute Stroke Trial (HeadPoST) and early additional impairment on outcomes. b i Methods: /i /b Post hoc analyses of HeadPoST, an international, cluster-randomized crossover trial of lying-flat versus sitting-up head positioning in acute stroke. Associations of early additional impairment, defined as change in modified Rankin scale (mRS) scores from premorbid levels (estimated at baseline) to Day 7 (“early ΔmRS”), and poor outcome (mRS score 3–6) at Day 90 were determined with generalized linear mixed model. Heterogeneity of the trial treatment effect was tested according to premorbid mRS scores 0–1 versus 2–5. b i Results: /i /b Of 8,285 patients (38.9% female, mean age 68 ± 13 years) with complete data, there were 1,984 (23.9%) with premorbid functional impairment (mRS 2–5). A significant linear association was evident for early ∆mRS and poor outcome (per 1-point increase in ΔmRS, adjusted odds ratio 1.20, 95% confidence interval 1.14–1.27 i /i & #x3c 0.0001). Patients with greater premorbid functional impairment were less likely to develop additional impairment, but their risk of poor 90-day outcome significantly increased with increasing (worse) premorbid mRS scores (linear trend i /i & #x3c 0.0001). There was no heterogeneity of the trial treatment effect by level of premorbid function. b i Conclusions: /i /b Early poststroke functional impairment that exceeded premorbid levels was associated with worse 90-day outcome, and this association increased with greater premorbid functional impairment. Yet, including premorbid impaired patients in the HeadPoST did not materially affect the subsequent treatment effect. b i Clinical Trial Registration: /i /b HeadPoST is registered at www.ClinicalTrials.gov (NCT02162017).
Admission Heart Rate Predicts Poor Outcomes in Acute Intracerebral Hemorrhage: The Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial Studies.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2016
DOI: 10.1161/STROKEAHA.115.012382
Abstract: Faster heart rate predicts higher mortality in coronary heart disease and acute ischemic stroke, but its prognostic significance in intracerebral hemorrhage remains uncertain. We aimed to determine the effect of admission heart rate on clinical and imaging outcomes in patients with intracerebral hemorrhage. A post hoc pooled analysis of the pilot and main phases of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT 1 and 2). Clinical outcomes were mortality and modified Rankin Scale score at 90 days and imaging outcome was absolute growth in hematoma volume during the initial 24 hours. Patients were ided into 4 categories according to baseline heart rate ( , 65–74, 75–84, and ≥85 bpm) and analyzed using multivariable adjusted models with the lowest heart rate group as the reference. Of 3185 patients with available data, higher admission heart rate was associated with both mortality and worse modified Rankin Scale score: adjusted hazard ratio for heart rate (≥85 versus bpm) 1.50 (95% confidence interval, 1.07–2.11) and adjusted odds ratio 1.33 (95% confidence interval, 1.08–1.63), respectively (both P -trend .05). There was no significant relationship between heart rate and absolute growth in hematoma volume ( P -trend, 0.196). Higher admission heart rate is independently associated with death and poor functional outcome after acute intracerebral hemorrhage. URL: www.clinicaltrials.gov . Unique identifier: NCT00226096 and NCT00716079.
Head Position and Cerebral Blood Flow Velocity in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis
Publisher: S. Karger AG
Date: 2014
DOI: 10.1159/000362533
Abstract: b i Background: /i /b Patients with acute ischemic stroke (AIS) have impaired vasomotor reactivity, especially in the affected cerebral hemisphere, such that they may depend directly on systemic blood pressure to maintain perfusion to vulnerable ‘at risk' penumbral tissue. As the sitting up position may affect cerebral perfusion by decreasing cerebral blood flow (CBF) in salvageable tissue, positioning AIS patients with their head in a lying flat position could increase CBF through collateral circulation or gravitational force. We wished to quantify the effect of different head positions on mean flow velocity (MFV) by transcranial Doppler ultrasonography (TCD) in AIS patients to assess the potential for benefit (or harm) of head positioning in a clinical trial. b i Methods: /i /b We performed a systematic review and meta-analysis of observational studies with TCD to evaluate differences in cerebral MFV between the lying flat and sitting up head positions in AIS. For each study and each comparison, we obtained the mean value of changes in MFV and its variance. b i Results: /i /b A total of 303 studies were identified, but 298 were excluded for varying reasons 4 papers met the inclusion criteria and 57 patients were included in the meta-analysis for calculation of the overall mean difference in MFV. We found a significant increase in MFV from a bed angle of 30 to 15° (4.6 cm/s, 95% confidence interval, CI, 2.9-6.2, p 0.001) and from 30 to 0° (8.3 cm/s, 95% CI 5.3-11.3, p 0.001) in the affected hemisphere but not on the normal side in AIS patients. b i Conclusions: /i /b In AIS patients, MFV increased significantly in the side affected by the stroke but not in the unaffected side when they were positioned in a lying flat head position at 0 or 15° compared to an upright head position at 30°. The clinical significance of these findings is now undergoing further randomized evaluation in the international multicenter Head Position in Acute Stroke Trial (HeadPoST).
The Relationship Between Smoking and Replicated Sequence Variants on Chromosomes 8 and 9 With Familial Intracranial Aneurysm
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2010
DOI: 10.1161/STROKEAHA.109.574640
Abstract: Background and Purpose— The purpose of this study was to replicate the previous association of single nucleotide polymorphisms (SNPs) with risk of intracranial aneurysm (IA) and to examine the relationship of smoking with these variants and the risk of IA. Methods— White probands with an IA from families with multiple affected members were identified by 26 clinical centers located throughout North America, New Zealand, and Australia. White control subjects free of stroke and IA were selected by random digit dialing from the Greater Cincinnati population. SNPs previously associated with IA on chromosomes 2, 8, and 9 were genotyped using a TaqMan assay or were included in the Affymetrix 6.0 array that was part of a genomewide association study of 406 IA cases and 392 control subjects. Logistic regression modeling tested whether the association of replicated SNPs with IA was modulated by smoking. Results— The strongest evidence of association with IA was found with the 8q SNP rs10958409 (genotypic P =9.2×10 −5 allelic P =1.3×10 −5 OR=1.86, 95% CI: 1.40 to 2.47). We also replicated the association with both SNPs on chromosome 9p, rs1333040 and rs10757278, but were not able to replicate the previously reported association of the 2 SNPs on chromosome 2q. Statistical testing showed a multiplicative relationship between the risk alleles and smoking with regard to the risk of IA. Conclusion— Our data provide complementary evidence that the variants on chromosomes 8q and 9p are associated with IA and that the risk of IA in patients with these variants is greatly increased with cigarette smoking.
Driving in stroke survivors aged 18-65 years: The Psychosocial Outcomes In StrokE (POISE) Cohort Study
Publisher: SAGE Publications
Date: 09-07-2016
Abstract: There is limited information regarding return to driving after stroke. To determine the frequency and predictors of return to driving within 1 month of acute stroke in younger (age 18–65 years) adults. POISE (Psychosocial Outcomes In StrokE) was a cohort study conducted in Australia between October 2008 and June 2010. Consecutive patients (age 18–65 years) with a recent (≤28 days) acute stroke were recruited. Validated demographic, clinical, mental health, cognitive, and disability measures including return to driving were obtained. Multivariable logistic regression was used to determine factors associated with return to driving within 1 month of stroke. Among 359 participants who were legally able to drive before stroke, 96 (26.7%) returned to driving within 1 month. Compared to those without an early return to driving ( n = 263), drivers were more often male, the main income earner, in paid work before stroke and without symptoms of depression or fatigue. Independence in activities of daily living (odds ratio (OR) 30.05, 95% confidence interval (CI) 3.85–234.45), not recalling receiving advice on driving cessation (OR 5.55, 95% CI 2.86–11.11), and having returned to paid work (OR 3.93, 95% CI 1.94–7.96) were associated with early return to driving. One in four young adults resumed driving within a month, contrary to guideline recommendations. These data reinforce the importance of deciding who is responsible for determining fitness to drive after stroke, when, and whether it is reasonable to enforce driving restrictions on those with minimal disability who are fit to return to work. Australian New Zealand Clinical Trials Registry ANZCTRN 12608000459325.
Triggers of subarachnoid hemorrhage: Role of physical exertion, smoking, and alcohol in the Australasian Cooperative Research on Subarachnoid Hemorrhage Study (ACROSS)
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2003
DOI: 10.1161/01.STR.0000077015.90334.A7
Abstract: Background and Purpose— Unaccustomed strenuous physical exertion can trigger myocardial infarction, but little is known about the mechanisms precipitating subarachnoid hemorrhage (SAH). Methods— We identified all cases of first-ever SAH among the combined populations (2.8 million) of 4 urban centers in Australia and New Zealand. Information on the type, time, and intensity of exposures in the 26 hours before the onset of SAH was ascertained by structured interviews. We used the case-crossover technique to assess the risk of SAH associated with transient exposures of moderate to extreme physical exertion, heavy cigarette smoking, and binge alcohol consumption. Results— We registered 432 first-ever cases of SAH (62% women mean age, 56.5 years). A definite time of onset of SAH was established for 393 patients (91%), and information on the levels of physical activity in the preceding 26 hours was obtained in 338 (78%). Of these patients, 19% engaged in moderate to extreme exertion (≥5 metabolic equivalents) in the 2 hours before SAH, which was associated with a tripling in the risk of SAH (odds ratio [OR], 2.7 95% CI, 1.6 to 4.6). There was no evidence of any association between heavy cigarette smoking or binge drinking and risk of SAH in the subsequent 2 hours (OR, 1.1 95% CI, 0.4 to 3.7 and OR, 0.41 95% CI, −∞ to 5.3). Habitual exercise did not appear to alter the risk of SAH associated with moderate to extreme exertion. Conclusions— Moderate to extreme physical exertion tripled the risk of SAH, but there was no association between transient heavy smoking or binge drinking and risk of SAH. These data suggest that heavy physical activity may trigger SAH.
Influenza-associated cardiovascular mortality in older adults in Beijing, China: a population-based time-series study
Publisher: BMJ
Date: 11-2020
DOI: 10.1136/BMJOPEN-2020-042487
Abstract: This study comprehensively estimated the excess cardiovascular disease (CVD) mortality attributable to influenza in an older (age ≥65 years) population. Ecological study. Aggregated data from administrative systems on CVD mortality, influenza surveillance and meteorological data in Beijing, China. Excess overall CVD, and separately for ischaemic heart disease (IHD), ischaemic stroke, haemorrhagic stroke mortality attributable to influenza, adjusting for influenza activity, time trend, seasonality and ambient temperature. CVD (risk ratio (RR) 1.02, 95% CI 1.01, 1.02), IHD (RR 1.01, 95% CI 1.01, 1.02), ischaemic stroke (RR=1.03, 95% CI 1.02, 1.04), but not haemorrhagic stroke (RR=1.00, 95% CI 0.99, 1.01) mortality, were significantly associated with every 10% increase in influenza activity. An increase in circulating A(H1N1)09pdm, A(H3N2) and B type virus were all significantly associated with CVD and ischaemic stroke mortality, but only A(H3N2) and B type virus with IHD mortality. The strongest increase in disease mortality was in the same week as the increase in influenza activity. Annual excess CVD mortality rate attributable to influenza ranged from 54 to 96 per 100 000 population. The 3%–6% CVD mortality attributable to influenza activity was related to an annual excess of 916–1640 CVD deaths in Beijing, China. Influenza activity has moderate to strong associations with CVD, IHD and ischaemic stroke mortality in older adults in China. Promoting influenza vaccination could have major health benefit in this population. Influenza may trigger serious CVD events. An estimation of excess CVD mortality attributable to influenza has particular relevance in China where vaccination is low and CVD burden is high. This study analysed data at the population level (age ≥65 years) using linked aggregated data from administrative systems on CVD mortality, influenza surveillance and meteorological data during 2011 to 2018. Quasi-Poisson regression models were used to estimate the excess overall CVD, and separately for IHD, ischaemic stroke, haemorrhagic stroke mortality attributable to influenza, adjusting for influenza activity, time trend, seasonality and ambient temperature. Analyses were also undertaken for influenza subtypes (A(H1N1)09pdm, A(H3N2) and B viruses), and mortality risk with time lags of 1–5 weeks following influenza activity in the current week.
Quality of Care and One-Year Outcomes in Patients with Diabetes Hospitalised for Stroke or TIA: A Linked Registry Study
Publisher: Elsevier BV
Date: 11-2021
DOI: 10.1016/J.JSTROKECEREBROVASDIS.2021.106083
Abstract: To evaluate key quality indicators for acute care and one-year outcomes following acute ischaemic stroke (IS), intracerebral haemorrhage (ICH), or transient ischaemic attack (TIA) by diabetes status. Observational cohort study (2009-2013) using linked data from the Australian Stroke Clinical Registry and hospital records. Diabetes was ascertained through review of hospital records. Multilevel regression models were used to evaluate the association between diabetes and outcomes, including discharge destination, and mortality and hospital readmissions within one-year of stroke/TIA. Among 14,132 patients (median age 76 years, 46% female), 22% had diabetes. Compared to patients without diabetes, those with diabetes were equally likely to receive stroke unit care, but were more often discharged on antihypertensive agents (79% vs. 68%) or with a care plan (50% vs. 47%). In patients with TIA, although 86% returned directly home after acute care, those with diabetes more often had a different discharge destination than those without diabetes. Diabetes was associated with greater all-cause mortality (hazard ratio 1.13, 95% CI 1.04-1.23) in patients with IS/ICH and with both greater all-cause (1.81, CI 1.35-2.43) and CVD mortality (1.75, CI 1.06-2.91) in patients with TIA. Similarly, diabetes was associated with greater rates of all-cause readmission in both patients with IS/ICH and TIA. Despite good adherence to best care standards for acute stroke/TIA, patients with comorbid diabetes had worse outcomes at one-year than those without comorbid diabetes. Associations of diabetes with poorer outcomes were more pronounced in patients with TIA than those with IS/ICH.
Telephone follow-up was more expensive but more efficient than postal in a national stroke registry
Publisher: Elsevier BV
Date: 08-2013
DOI: 10.1016/J.JCLINEPI.2013.03.005
Abstract: To compare the efficiency and differential costs of telephone- vs. mail-based assessments of outcome in patients registered in a national clinical quality of care registry, the Australian Stroke Clinical Registry (AuSCR). The participants admitted to hospital with stroke or transient ischemic attack were randomly assigned to complete a health questionnaire by mail or telephone interview at 3-6 months postevent. Response rate, researcher burden, and costs of each method were compared. Compared with the participants in the mail questionnaire arm (n=277 50% female mean age: 70 years), those in the telephone arm (n=282 45% female mean age: 68 years) required a shorter time to complete the follow-up (mean difference: 24.2 days 95% confidence interval [CI]: 15.0, 33.5 days). However, the average cost of completing a telephone follow-up was greater (US$20.87 vs. US$13.86) and had a similar overall response to the mail method (absolute difference: 0.57% 95% CI: -4.8%, 6%). Posthospital stroke outcome data were slower to collect by mail, but the method achieved a similar completion rate and was significantly cheaper to conduct than follow-up telephone interview. Findings are informative for planning outcome data collection in large numbers of patients with acute stroke.
Left ventricular hypertrophy and incident cognitive decline in older adults with hypertension
Publisher: Springer Science and Business Media LLC
Date: 04-2022
DOI: 10.1038/S41371-022-00681-1
Abstract: The association between raised blood pressure and increased risk of subsequent cognitive decline is well known. Left ventricular hypertrophy (LVH), as a marker of hypertensive target organ damage, may help identify those at risk of cognitive decline. We assessed whether LVH was associated with subsequent cognitive decline or dementia in hypertensive participants aged ≥80 years in the randomized, placebo-controlled Hypertension in the Very Elderly Trial. LVH was assessed using 12-lead electrocardiography (ECG) based on the Cornell Product (CP-LVH), Sokolow-Lyon (SL-LVH), and Cornell Voltage (CV-LVH) criteria. The Mini-Mental State Examination (MMSE) was used to assess cognitive function at baseline and annually. A fall in MMSE to or an annual fall of points were defined as cognitive decline and triggered dementia screening (Diagnostic Statistical Manual IV). Death was defined as a competing event. Fine-Gray regression models were used to examine the relationship between baseline LVH and cognitive outcomes. There were 2645 in the analytical s le, including 201 (7.6%) with CP-LVH, 225 (8.5%) SL-LVH and 251 (9.5%) CV-LVH. CP-LVH was associated with increased risk of cognitive decline, subdistribution hazard ratio (sHR)1.3 (95% confidence interval (CI) 1.01–1.67) in multivariate analyses. SL-LVH and CV-LVH were not associated with cognitive decline (sHR1.06 (95% CI 0.82–1.37) and sHR1.13 (95% CI 0.89–1.43), respectively). LVH was not associated with dementia. LVH may be related to subsequent cognitive decline, but evidence was inconsistent depending on ECG criterion and there were no associations with incident dementia. Additional work is needed to understand the relationships between blood pressure, LVH assessment and cognition.
Temporal trends in diagnosis, treatment, and outcome for non-ST-segment elevation acute coronary syndrome in three regions of China, 2008-2015.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-08-2021
Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data
Publisher: Elsevier BV
Date: 08-2014
Genome-Wide Association Study of Intracranial Aneurysm Identifies a New Association on Chromosome 7
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2014
DOI: 10.1161/STROKEAHA.114.006096
Abstract: Common variants have been identified using genome-wide association studies which contribute to intracranial aneurysms (IA) susceptibility. However, it is clear that the variants identified to date do not account for the estimated genetic contribution to disease risk. Initial analysis was performed in a discovery s le of 2617 IA cases and 2548 controls of white ancestry. Novel chromosomal regions meeting genome-wide significance were further tested for association in 2 independent replication s les: Dutch (717 cases 3004 controls) and Finnish (799 cases 2317 controls). A meta-analysis was performed to combine the results from the 3 studies for key chromosomal regions of interest. Genome-wide evidence of association was detected in the discovery s le on chromosome 9 ( CDKN2BAS rs10733376: P .0×10 −11 ), in a gene previously associated with IA. A novel region on chromosome 7, near HDAC9 , was associated with IA (rs10230207 P =4.14×10 −8 ). This association replicated in the Dutch s le ( P =0.01) but failed to show association in the Finnish s le ( P =0.25). Meta-analysis results of the 3 cohorts reached statistical significant ( P =9.91×10 −10 ). We detected a novel region associated with IA susceptibility that was replicated in an independent Dutch s le. This region on chromosome 7 has been previously associated with ischemic stroke and the large vessel stroke occlusive subtype (including HDAC9 ), suggesting a possible genetic link between this stroke subtype and IA.
Do men and women respond differently to blood pressure-lowering treatment? Results of prospectively designed overviews of randomized trials
Publisher: Oxford University Press (OUP)
Date: 20-05-2008
Abstract: Large-scale observational studies show that lower blood pressure is associated with lower cardiovascular risk in both men and women although some studies have suggested that different outcomes between the sexes may reflect different responses to blood pressure-lowering treatment. The aims of these overview analyses were to quantify the effects of blood pressure-lowering treatment in each sex and to determine if there are important differences in the proportional benefits of treatment between men and women. Thirty-one randomized trials that included 103,268 men and 87,349 women contributed to these analyses. For each outcome and each comparison summary estimates of effect and 95% confidence intervals were calculated for men and women using a random-effects model. The consistency of the effects of each treatment regimen across the sexes was examined using chi(2) tests of homogeneity. Achieved blood pressure reductions were comparable for men and women in every comparison made. For the primary outcome of total major cardiovascular events there was no evidence that men and women obtained different levels of protection from blood pressure lowering or that regimens based on angiotensin-converting-enzyme inhibitors, calcium antagonists, angiotensin receptor blockers, or diuretics/beta-blockers were more effective in one sex than the other (all P-homogeneity > 0.08). All of the blood pressure-lowering regimens studied here provided broadly similar protection against major cardiovascular events in men and women. Differences in cardiovascular risks between sexes are unlikely to reflect differences in response to blood pressure-lowering treatments.
Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century
Publisher: Elsevier BV
Date: 2003
DOI: 10.1016/S1474-4422(03)00266-7
Abstract: This overview of population-based studies of incidence, prevalence, mortality, and case-fatality of stroke was based on studies from 1990. Incidence (first stroke in an in idual's lifetime) and prevalence were computed by age, sex, and stroke type. Age-standardised incidence and prevalence with the corresponding 95% CI were plotted for each study to facilitate comparisons. The review shows that the burden of stroke is high and is likely to increase in future decades as a result of demographic and epidemiological transitions in populations. The main features of stroke epidemiology include modest geographical variation in incidence, prevalence, and case-fatality among the--predominantly white--populations studied so far, and a stabilisation or reversal in the declining secular trends in the pre-1990s rates, especially in older people. However, further research that uses the best possible methods to study the incidence, risk factors, and outcome of stroke are urgently needed in other populations of the world, especially in less developed countries where the risk of stroke is high, lifestyles are changing rapidly, and population restructuring is occurring.
Ambient Temperature and Stroke Occurrence: A Systematic Review and Meta-Analysis
Publisher: MDPI AG
Date: 12-07-2016
Determinants and Prognostic Significance of Hematoma Sedimentation Levels in Acute Intracerebral Hemorrhage
Publisher: S. Karger AG
Date: 16-12-2015
DOI: 10.1159/000442532
Abstract: b i Background: /i /b This study aimed at identifying the determinants and prognostic significance of a sedimentation level (fluid-blood level) in the hematoma among patients with acute intracerebral hemorrhage (ICH) who participated in the main Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). b i Methods: /i /b Post-hoc analysis of the INTERACT2 dataset, a randomized controlled trial of patients with acute ICH with elevated systolic blood pressure (SBP), randomly assigned to intensive (target SBP mm Hg) or guideline-based ( mm Hg) BP management. Patients with a sedimentation level at baseline assessment on CT, and modified Rankin Scale score at 90-day, were included in these analyses. Factors associated with a sedimentation level and its significance in relation to 90-day clinical outcomes were assessed in univariable and multivariable logistic regression models. b i Results: /i /b Of 2,065 participants, 19 (1%) had sedimentation level on baseline CT, which was independently associated with warfarin use (p = 0.006) and lobar ICH (p = 0.025). Sedimentation level was also associated with death or major disability at 90-day in both crude (84 vs. 53% p = 0.014) and multivariable analyses adjusted for age, gender, Chinese region, warfarin use, baseline National Institutes of Health Stroke Scale score, onset to CT time, volume and location of ICH, intraventricular extension, and randomized intensive BP lowering (OR 3.94, 95% CI 1.01-15.37 p = 0.049). b i Conclusions: /i /b The presence of hematoma sedimentation level on baseline CT is associated with warfarin use and lobar location of ICH, and predicts a worse outcome. Although uncommon, sedimentation level is an easily detectable prognostic factor in acute ICH.
Trends in Incidence and Outcome of Stroke in Perth, Western Australia During 1989 to 2001: The Perth Community Stroke Study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2008
DOI: 10.1161/STROKEAHA.107.493643
Abstract: Background and Purpose— We studied temporal trends in major stroke outcomes in Perth, Western Australia (WA), comparing 3 12-month periods, roughly 5 years apart, between 1989 and 2001. Methods— The Perth Community Stroke Study (PCSS) used uniform definitions and procedures in a representative segment (approximately 143 000 people in the year 2000) of Perth, WA. Crude and age-standardized incidence and 28-day case fatality for stroke in the different study periods were compared using Poisson regression. We also undertook temporal comparisons of severity, risk factors, and management of stroke to define the basis for any changes in rates. Data are reported with 95% confidence intervals (CI). Results— There were 251, 213, and 183 first-ever strokes identified in the first, second, and third study periods, respectively, reflecting significant declines in stroke rates overall, for major age groups, and for both ischemic stroke and intracerebral hemorrhage. The decline in rates was greater in men than women. Compared with the 1989 to 1990 period, sex- and age-adjusted rates declined by 25% (95% CI 10% to 37%) in 1995 to 1996, and by 43% (95% CI 31% to 53%) in 2000 to 2001, corresponding to a 5.5% average annual decrease overall. There were correspondingly significant reductions in the frequencies of key risk factors among cases. However, early case fatality remained stable, both overall and for major pathological subtypes of stroke. Conclusions— These data confirm significant declines in the incidence of stroke on the western side of Australia, coincident with some improvement in the vascular risk profile of cases in the population. Decreasing risk rather than improving survival appears to be the main driver of falling mortality from stroke in this population.
Intensive Care Unit Admission for Patients in the INTERACT2 ICH Blood Pressure Treatment Trial: Characteristics, Predictors, and Outcomes
Publisher: Springer Science and Business Media LLC
Date: 20-12-2016
DOI: 10.1007/S12028-016-0365-4
Abstract: Wide variation exists in criteria for accessing intensive care unit (ICU) facilities for managing patients with critical illnesses such as acute intracerebral hemorrhage (ICH). We aimed to determine the predictors of admission, length of stay, and outcome for ICU among participants of the main Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). INTERACT2 was an international, open, blinded endpoint, randomized controlled trial of 2839 ICH patients (<6 h) and elevated systolic blood pressure (SBP) allocated to receive intensive (target SBP <140 mmHg within 1 h) or guideline-recommended (target SBP <180 mmHg) BP-lowering treatment. The primary outcome was death or major disability, defined by modified Rankin scale scores 3-6 at 90 days. Logistic regression and propensity score analyses were used to determine independent associations. Predictors of ICU admission included younger age, recruitment in China, prior ischemic/undetermined stroke, high SBP, severe stroke [National Institute of Health stroke scale (NIHSS) score ≥15], large ICH volume (≥15 mL), intraventricular hemorrhage (IVH) extension, early neurological deterioration, intubation and surgery. Determinants of prolonged ICU stay (≥5 days) were prior antihypertensive use, NIHSS ≥15, large ICH volume, lobar ICH location, IVH, early neurological deterioration, intubation and surgery. ICU admission was associated with higher-risk major disability at 90-day assessment compared to those without ICU admission. This study presents prognostic variables for ICU management and outcome of ICH patients included in a large international cohort. These data may assist in the selection and counseling of patients and families concerning ICU admission.
Influence of Renal Impairment on Outcome for Thrombolysis-Treated Acute Ischemic Stroke: ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study) Post Hoc Analysis.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2017
DOI: 10.1161/STROKEAHA.117.017808
Abstract: Renal dysfunction (RD) is associated with poor prognosis after stroke. We assessed the effects of RD on outcomes and interaction with low- versus standard-dose alteplase in a post hoc subgroup analysis of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study). A total of 3220 thrombolysis-eligible patients with acute ischemic stroke (mean age, 66.5 years 37.8% women) were randomly assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) intravenous alteplase within 4.5 hours of symptom onset. Six hundred and fifty-nine (19.8%) patients had moderate-to-severe RD (estimated glomerular filtration rate, mL/min per 1.73 m 2 ) at baseline. The impact of RD on death or disability (modified Rankin Scale scores, 2–6) at 90 days, and symptomatic intracerebral hemorrhage, was assessed in logistic regression models. Compared with patients with normal renal function ( mL/min per 1.73 m 2 ), those with severe RD ( mL/min per 1.73 m 2 ) had increased mortality (adjusted odds ratio, 2.07 95% confidence interval, 0.89–4.82 P =0.04 for trend) every 10 mL/min per 1.73 m 2 lower estimated glomerular filtration rate was associated with an adjusted 9% increased odds of death from thrombolysis-treated acute ischemic stroke. There was no significant association with modified Rankin Scale scores 2 to 6 (adjusted odds ratio, 1.03 95% confidence interval, 0.62–1.70 P =0.81 for trend), modified Rankin Scale 3 to 6 (adjusted odds ratio, 1.20 95% confidence interval, 0.72–2.01 P =0.44 for trend), or symptomatic intracerebral hemorrhage, or any heterogeneity in comparative treatment effects between low-dose and standard-dose alteplase by RD grades. RD is associated with increased mortality but not disability or symptomatic intracerebral hemorrhage in thrombolysis-eligible and treated acute ischemic stroke patients. Uncertainty persists as to whether low-dose alteplase confers benefits over standard-dose alteplase in acute ischemic stroke patients with RD. URL: www.clinicaltrials.gov . Unique identifier: NCT01422616.
Differential effects of hypertension in the aetiology of major intracerebral haemorrhage subtypes
Publisher: BMJ
Date: 20-06-2006
Progress-Defining Risk Factors for Stroke Prevention
Publisher: S. Karger AG
Date: 2021
DOI: 10.1159/000516996
Statistical analysis plan for evaluating low- vs. standard-dose alteplase in the ENhanced Control of Hypertension and Thrombolysis strokE stuDy (ENCHANTED).
Publisher: SAGE Publications
Date: 18-08-2015
DOI: 10.1111/IJS.12602
Abstract: The ENhanced Control of Hypertension And Thrombolysis strokE stuDy trial is a 2 × 2 quasi-factorial active-comparison, prospective, randomized, open, blinded endpoint clinical trial that is evaluating in thrombolysis-eligible acute ischemic stroke patients whether: (1) low-dose (0·6 mg/kg body weight) intravenous alteplase has noninferior efficacy and lower risk of symptomatic intracerebral hemorrhage compared with standard-dose (0·9 mg/kg body weight) intravenous alteplase and (2) early intensive blood pressure lowering (systolic target 130–140 mmHg) has superior efficacy and lower risk of any intracerebral hemorrhage compared with guideline-recommended blood pressure control (systolic target mmHg). To outline in detail the predetermined statistical analysis plan for the ‘alteplase dose arm’ of the study. All data collected by participating researchers will be reviewed and formally assessed. Information pertaining to the baseline characteristics of patients, their process of care, and the delivery of treatments will be classified, and for each item, appropriate descriptive statistical analyses are planned with appropriate comparisons made between randomized groups. For the trial outcomes, the most appropriate statistical comparisons to be made between groups are planned and described. A statistical analysis plan was developed for the results of the alteplase dose arm of the study that is transparent, available to the public, verifiable, and predetermined before completion of data collection. We have developed a predetermined statistical analysis plan for the ENhanced Control of Hypertension And Thrombolysis strokE stuDy alteplase dose arm which is to be followed to avoid analysis bias arising from prior knowledge of the study findings.
Ethnic disparities in incidence of stroke subtypes: Auckland Regional Community Stroke Study, 2002–2003
Publisher: Elsevier BV
Date: 02-2006
Comparison of ABC Methods with Computerized Estimates of Intracerebral Hemorrhage Volume: The INTERACT2 Study
Publisher: S. Karger AG
Date: 13-12-2019
DOI: 10.1159/000504531
Abstract: b i Background and Purpose: /i /b Hematoma volume is a key determinant of outcome in acute intracerebral hemorrhage (ICH). We aimed to compare estimates of ICH volume between simple (ABC/2, length, width, and height) and gold standard planimetric software approaches. b i Methods: /i /b Data are from the second Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). Multivariable linear regression was used to compare ICH volumes on baseline CT scans using the ABC/2, modified ABC/2 (mABC/2), and MIStar software. Other aspects of ICH morphology examined included location, irregularity, heterogeneity, intraventricular and subarachnoid hemorrhage extension (SAH) of hematoma, and associated white matter lesions and brain atrophy. b i Results: /i /b In 2,084 patients with manual and semiautomated measurements, median (IQR) ICH volumes for each approach were: ABC/2 11.1 (5.11–20.88 mL), mABC/2 7.8 (3.88–14.11 mL), and MIStar 10.7 (5.59–18.66 mL). Median differences between ABC/2 and MIStar, and mABC/2 and MIStar were 0.34 (–1.01 to 2.96) and –2.4 (–4.95 to –0.7416), respectively. Hematoma volumes differed significantly with irregular shape (ABC/2 and MIStar, i /i & #x3c 0.001 mABC/2 and MIStar, i /i = 0.007) and larger volumes (mABC/2 and MIStar, i /i & #x3c 0.001 ABC/2 and MIStar, i /i = 0.07). ICH with SAH showed a significant discrepancy between ABC/2 and MIStar ( i /i & #x3c 0.001). b i Conclusions: /i /b Overall, ABC/2 performs better than mABC/2 in estimating ICH volume. The largest discrepancies were evidenced against automated software for irregular-shaped and large ICH with SAH, but the clinical significance of this is uncertain.
Statistical Analysis Plan for the INTEnsive Care Bundle with Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial: A Stepped-Wedge Cluster Randomized Controlled Trial
Publisher: S. Karger AG
Date: 05-09-2023
DOI: 10.1159/000526384
Abstract: The third INTEnsive care bundle with blood pressure Reduction in Acute Cerebral hemorrhage Trial (INTERACT3) is an international, multicenter, stepped-wedge (4 phases/3 steps) cluster randomized trial involving 110 hospitals in mainly low- and middle-income countries during 2017–2022. The aim is to determine the effectiveness of a goal-directed care bundle of intensive blood pressure (BP) lowering, glycemic control, antipyrexia, and anticoagulation reversal treatment versus usual standard of care, in patients with acute intracerebral hemorrhage (ICH). After a “usual care” period, hospitals were randomly allocated to implementing care-bundle protocols for control targets (systolic BP & #x3c mm Hg glucose 6.1–7.8/7.8–10.0 mmol/L according to diabetes mellitus status temperature ≤37.5°C normalization of anticoagulation). A s le size of 8,360 patients (mean 19 per phase per site) provides 90% power (α = 0.05) for a 5.6% absolute improvement in the primary outcome of scores on the modified Rankin scale at 6 months, analyzed by ordinal logistic regression. A detailed statistical analysis plan (SAP) was developed to prespecify the method of analysis for all outcomes and key variables collected in the trial. The primary analysis will use ordinal logistic regression adjusted for the stepped-wedge design. The SAP also includes planned sensitivity analyses, including covariate adjustments, missing data imputations, and subgroup analysis. This SAP allows transparent, verifiable, and prespecified analyses in consideration of the challenges in conducting the study during the COVID pandemic. It also avoids analysis bias arising from prior knowledge of the findings in determining the benefits and harms of a care bundle in acute ICH.
Effectiveness of intravenous r-tPA versus UK for acute ischaemic stroke: a nationwide prospective Chinese registry study
Publisher: BMJ
Date: 26-04-2021
Abstract: Intravenous recombinant tissue plasminogen activator (r-tPA) and urokinase (UK) are both recommended for the treatment of acute ischaemic stroke (AIS) in China, but with few comparative outcome data being available. We aimed to compare the outcomes of these two thrombolytic agents for the treatment of patients within 4.5 hours of onset of AIS in routine clinical practice in China. A pre-planned, prospective, nationwide, multicentre, real-world registry of consecutive patients with AIS (age ≥18 years) who received r-tPA or UK within 4.5 hours of symptom onset according to local decision-making and guideline recommendations during 2017–2019. The primary effectiveness outcome was the proportion of patients with an excellent functional outcome (defined by modified Rankin scale scores 0 to 1) at 90 days. The key safety endpoint was symptomatic intracranial haemorrhage according to standard definitions. Multivariable logistic regression was used for comparative analysis, with adjustment according to propensity scores to ensure balance in baseline characteristics. Overall, 4130 patients with AIS were registered but 320 had incomplete or missing data, leaving 3810 with available data for analysis of whom 2666 received r-tPA (median dose 0.88 (IQR 0.78–0.90) mg/kg) and 1144 received UK (1.71 (1.43–2.00)×10 4 international unit per kilogram). There were several significant intergroup differences in patient characteristics: r-tPA patients were more educated, had less history of stroke, lower systolic blood pressure, greater neurological impairment and shorter treatment times from symptom onset than UK patients. However, in adjusted analysis, the frequency of excellent outcome (OR 1.18, 95% CI 1.00 to 1.40, p=0.052) and symptomatic intracranial haemorrhage (OR 0.70, 95% CI 0.33 to 1.47, p=0.344) were similar between groups. UK may be as effective and carry a similar safety profile as r-tPA in treating mild to moderate AIS within guidelines in China. www.clinicaltrials.gov . unique identifier: NCT02854592 .
Early supported discharge services for stroke patients: a meta-analysis of individual patients' data
Publisher: Elsevier BV
Date: 02-2005
Serum Phosphate and 1-Year Outcome in Patients With Acute Ischemic Stroke and Transient Ischemic Attack
Publisher: Frontiers Media SA
Date: 14-04-2021
DOI: 10.3389/FNEUR.2021.652941
Abstract: Objective: To determine the association between serum phosphate level and 1-year clinical outcomes in patients with acute ischemic stroke and transient ischemic attack. Methods: We included 7,353 patients with acute ischemic stroke and transient ischemic attack from the China National Stroke Registry III for analysis. Participants were ided into 4 groups according to serum phosphate quartiles. Composite end point included recurrent stroke, myocardial infarction, other ischemic vascular events, and all-cause mortality. Poor functional outcome is defined as modified Rankin Scale score of 3 to 6. Multivariable Cox regression or logistic regression was used to evaluate the independent association of serum phosphate with 1-year all-cause mortality, recurrent stroke, composite end point and poor functional outcome. Results: The mean age of the included 7,353 patients was 62.5 years, and 68.6% of them were men. Plotting hazard ratios over phosphate levels suggested a U-shaped association especially for recurrent stroke and composite end point, and therefore the third quartile group was set as reference group. Compared with the third quartile of phosphate (1.06–1.20 mmol/L), the adjusted hazard ratios/odds ratios (95% CI) of the lowest quartile (& .94 mmol/L) were 0.98 (0.67–1.42) for all-cause mortality, 1.31 (1.05–1.64) for stroke recurrence, 1.26 (1.02–1.57) for composite end point, and 1.27 (1.01–1.61) for poor functional outcome, and the adjusted odds ratio of the highest quartile (≥1.2 mmol/L) was 1.40 (1.11–1.77) for poor functional outcome. Conclusions: Serum phosphate may be an independent predictor of stroke recurrence, composite end point and poor functional outcome after ischemic stroke.
The influence of psychiatric morbidity on return to paid work after stroke in younger adults: The auckland regional community stroke (ARCOS) study, 2002 to 2003
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2008
DOI: 10.1161/STROKEAHA.107.503219
Abstract: Background and Purpose— Few data exist on the determinants of return to paid work after stroke, yet participation in employment is vital to a person’s mental well-being and role in society. This study aimed to determine the frequency and determinants of return to work, in particular the effect of early psychiatric morbidity, in a population-based study of stroke survivors. Methods— The third Auckland Regional Community Stroke (ARCOS) study was a prospective, population-based, stroke incidence study undertaken in Auckland, New Zealand during 2002 to 2003. After a baseline assessment early after stroke, data were collected on all survivors at 1 and 6 months follow-up. Multiple variable logistic regression was used to determine predictors of return to paid work. Data are reported with odds ratios (OR) and 95% confidence intervals (CI). Results— Among 1423 patients registered with first-ever strokes, there were 210 previously in paid employment who survived to 6 months, of whom 155 (74%) completed the GHQ-28 and 112 (53%) had returned to paid work. Among those cognitively competent, psychiatric morbidity at 28 days was a strong independent predictor of not returning to work (Odds Ratio 0.39 95% CI 0.22 to 0.80). Non–New Zealand European ethnicity (OR 0.40 95% CI 0.17 to 0.91), prior part-time, as opposed to full-time, employment 0.36 (0.15 to 0.89), and not being functionally independent soon after the stroke 0.28 (0.13 to 0.59) were the other independent age- and gender-adjusted predictors of not successfully returning to paid work. Conclusions— About half of previously employed people return to paid employment after stroke, with psychiatric morbidity and physical disability being independent, yet potentially treatable, determinants of this outcome. Appropriate management of both emotional and physical sequelae would appear necessary for optimizing recovery and return to work in younger adults after stroke.
Capture-recapture is a potentially useful method for assessing publication bias
Publisher: Elsevier BV
Date: 04-2004
Depression after stroke-frequency, risk factors, andmortality outcomes
Publisher: American Medical Association (AMA)
Date: 10-2016
Reliability of intracerebral hemorrhage classification systems: A systematic review
Publisher: SAGE Publications
Date: 09-07-2016
Abstract: Accurately distinguishing non-traumatic intracerebral hemorrhage (ICH) subtypes is important since they may have different risk factors, causal pathways, management, and prognosis. We systematically assessed the inter- and intra-rater reliability of ICH classification systems. We sought all available reliability assessments of anatomical and mechanistic ICH classification systems from electronic databases and personal contacts until October 2014. We assessed included studies’ characteristics, reporting quality and potential for bias summarized reliability with kappa value forest plots and performed meta-analyses of the proportion of cases classified into each subtype. We included 8 of 2152 studies identified. Inter- and intra-rater reliabilities were substantial to perfect for anatomical and mechanistic systems (inter-rater kappa values: anatomical 0.78–0.97 [six studies, 518 cases], mechanistic 0.89–0.93 [three studies, 510 cases] intra-rater kappas: anatomical 0.80–1 [three studies, 137 cases], mechanistic 0.92–0.93 [two studies, 368 cases]). Reporting quality varied but no study fulfilled all criteria and none was free from potential bias. All reliability studies were performed with experienced raters in specialist centers. Proportions of ICH subtypes were largely consistent with previous reports suggesting that included studies are appropriately representative. Reliability of existing classification systems appears excellent but is unknown outside specialist centers with experienced raters. Future reliability comparisons should be facilitated by studies following recently published reporting guidelines.
Risk Factors for Subarachnoid Hemorrhage
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2005
DOI: 10.1161/01.STR.0000190838.02954.E8
Abstract: Background and Purpose— After a 1996 review from our group on risk factors for subarachnoid hemorrhage (SAH), much new information has become available. This article provides an updated overview of risk factors for SAH. Methods— An overview of all longitudinal and case-control studies of risk factors for SAH published in English from 1966 through March 2005. We calculated pooled relative risks (RRs) for longitudinal studies and odds ratios (ORs) for case-control studies, both with corresponding 95% CIs. Results— We included 14 longitudinal (5 new) and 23 (12 new) case-control studies. Overall, the studies included 3936 patients with SAH (892 cases in 14 longitudinal studies and 3044 cases in 23 case-control studies) for analysis. Statistically significant risk factors in longitudinal and case-control studies were current smoking (RR, 2.2 [1.3 to 3.6] OR, 3.1 [2.7 to 3.5]), hypertension (RR, 2.5 [2.0 to 3.1] OR, 2.6 [2.0 to 3.1]), and excessive alcohol intake (RR, 2.1 [1.5 to 2.8] OR, 1.5 [1.3 to 1.8]). Nonwhite ethnicity was a less robust risk factor (RR, 1.8 [0.8 to 4.2] OR, 3.4 [1.0 to 11.9]). Oral contraceptives did not affect the risk (RR, 5.4 [0.7 to 43.5] OR, 0.8 [0.5 to 1.3]). Risk reductions were found for hormone replacement therapy (RR, 0.6 [0.2 to 1.5] OR, 0.6 [0.4 to 0.8]), hypercholesterolemia (RR, 0.8 [0.6 to 1.2] OR, 0.6 [0.4 to 0.9]), and diabetes (RR, 0.3 [0 to 2.2] OR, 0.7 [0.5 to 0.8]). Data were inconsistent for lean body mass index (RR, 0.3 [0.2 to 0.4] OR, 1.4 [1.0 to 2.0]) and rigorous exercise (RR, 0.5 [0.3 to 1.0] OR, 1.2 [1.0 to 1.6]). In the studies included in the review, no other risk factors were available for the meta-analysis. Conclusions— Smoking, hypertension, and excessive alcohol remain the most important risk factors for SAH. The seemingly protective effects of white ethnicity compared to nonwhite ethnicity, hormone replacement therapy, hypercholesterolemia, and diabetes in the etiology of SAH are uncertain.
Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial
Publisher: Elsevier BV
Date: 11-2022
Lower target blood pressures are safe and effective for the prevention of recurrent stroke: the PROGRESS trial.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2006
Statistical analysis plan for the Head Position in Stroke Trial (HeadPoST): An international cluster cross-over randomized trial.
Publisher: SAGE Publications
Date: 24-03-2017
Abstract: There is evidence to indicate that the lying flat head position increases cerebral blood flow and oxygenation in patients with acute ischemic stroke, but how these physiological effects translate into clinical outcomes is uncertain. The Head Position in Stroke Trial aims to determine the comparative effectiveness of lying flat (0°) compared to sitting up (≥30°) head positioning, initiated within 24 h of hospital admission for patients with acute stroke. An international, pragmatic, cluster-randomized, crossover, open, blinded outcome assessed clinical trial. Each hospital with an established acute stroke unit (cluster) site was required to recruit up to 140 consecutive cases of acute stroke (one phase of head positioning before immediately crossing over to the other phase of head positioning), including both acute ischemic stroke and intracerebral hemorrhage, in each randomized head position as a ‘business as usual’ policy. To outline in detail the predetermined statistical analysis plan for the study. All accumulated data will be reviewed and formally assessed. Information regarding baseline characteristics of patients, their process of care and management will be outlined, and for each item, statistically relevant descriptive elements will be described. For the trial outcomes, the most appropriate statistical comparisons are described. A statistical analysis plan was developed that is transparent, verifiable, and predetermined before completion of data collection. We developed a predetermined statistical analysis plan for Head Position in Stroke Trial to avoid analysis bias arising from prior knowledge of the findings, in order to reliably quantify the benefits and harms of lying flat versus sitting up early after the onset of acute stroke. ClinicalTrials.gov identifier NCT02162017 ANZCTR identifier ACTRN12614000483651
CPAP increases physical activity in obstructive sleep apnea with cardiovascular disease
Publisher: American Academy of Sleep Medicine (AASM)
Date: 02-2021
DOI: 10.5664/JCSM.8792
Control of blood pressure in hypertensive neurological emergencies
Publisher: Springer Science and Business Media LLC
Date: 26-04-2014
DOI: 10.1007/S11906-014-0436-X
Abstract: Neurological hypertensive emergencies cause significant morbidity and mortality. Most occur in the setting of ischaemic stroke, spontaneous intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH), but other causes relate to hypertensive encephalopathy and reversible cerebral vasoconstriction syndrome (RCVS). Prompt and controlled reduction of blood pressure (BP) is necessary, although there remains uncertainty as to the optimal rate of decline and ideal antihypertensive agent. There is probably no single treatment strategy that covers all neurological hypertensive emergencies. Prompt diagnosis of the underlying disorder, recognition of its severity, and appropriate targeted treatment are required. Lack of comparative-effectiveness data leaves clinicians with limited evidence-based guidance in management, although significant developments have occurred recently in the field. In this article, we review the management of specific neurological hypertensive emergencies, with particular emphasis on recent evidence.
The emerging role of therapeutic hypothermia in acute stroke
Publisher: Elsevier BV
Date: 09-2003
Cluster randomized trial of influenza vaccination in patients with acute heart failure in China: A mixed-methods feasibility study.
Publisher: Public Library of Science (PLoS)
Date: 16-06-2023
DOI: 10.1371/JOURNAL.PGPH.0001947
Abstract: Uncertainties about the efficacy of influenza vaccination for populations with heart failure (HF) in preventing cardiovascular outcomes, as well as lack of effective vaccination strategies, may contribute to low vaccine coverage rate (VCR) in China and globally. We assessed the feasibility of a strategy to promote influenza vaccines in patients hospitalized with acute HF in China and to inform the design of a hybrid effectiveness-implementation cluster randomized trial to evaluate this strategy on mortality and hospital re-admission. We conducted a cluster randomized pilot trial involving 11 hospitals in Henan Province in China, with mixed-methods evaluation between December 2020 and April 2021. A process evaluation involved interviews with 51 key informants (patients, health professionals, policy makers). The intervention included education about influenza vaccination and availability of free vaccines administered prior to hospital discharge for HF patients, while usual care included attending community-based points of vaccination (PoV) for screening and vaccination. Implementation outcomes focused on reach, fidelity, adoption, and acceptability. Recruitment rates were assessed for trial feasibility. Effectiveness outcomes were influenza VCR, HF-specific rehospitalizations and mortality at 90 days. A total of 518 HF patients were recruited from 7 intervention and 4 usual care hospitals (mean of 45 participants per hospital per month). VCR was 89.9% (311/346, 86.1–92.8%) in the intervention group and 0.6% (1/172, 0.0–3.7%) in the control group. The process evaluation demonstrated reach to patients with lower socioeconomic and education status. There was good fidelity of the intervention components, with education and PoV set up processes being adapted to local hospital workflow and workforce capacity. Intervention was acceptable and adopted by patients and health professionals. However, outside of a trial setting, concerns were raised around vaccination reimbursement costs, workforce accountability and capacity. The intervention strategy appears feasible and acceptable for improving VCR in HF patients at county-level hospitals in China. Trial registration: This pilot trial is registered with the acronym PANDA II Pilot (Population Assessment of Influenza and Disease Activity) at ChiCTR.org.cn ( ChiCTR2000039081 ).
Effect of Treatment Delay, Stroke Type, and Thrombolysis on the Effect of Glyceryl Trinitrate, a Nitric Oxide Donor, on Outcome after Acute Stroke: A Systematic Review and Meta-Analysis of Individual
Publisher: Hindawi Limited
Date: 2016
DOI: 10.1155/2016/9706720
Abstract: Background. Nitric oxide (NO) donors are a candidate treatment for acute stroke and two trials have suggested that they might improve outcome if administered within 4–6 hours of stroke onset. We assessed the safety and efficacy of NO donors using in idual patient data (IPD) from completed trials. Methods. Randomised controlled trials of NO donors in patients with acute or subacute stroke were identified and IPD sought from the trialists. The effect of NO donor versus control on functional outcome was assessed using the modified Rankin scale (mRS) and death, by time to randomisation. Secondary outcomes included measures of disability, mood, and quality of life. Results. Five trials (4,197 participants) were identified, all involving glyceryl trinitrate (GTN). Compared with control, GTN lowered blood pressure by 7.4/3.3 mmHg. At day 90, GTN did not alter any clinical measures. However, in 312 patients randomised within 6 hours of stroke onset, GTN was associated with beneficial shifts in the mRS (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.34–0.78) and reduced death (OR 0.32, 95% CI 0.14–0.78). Conclusions. NO donors do not alter outcome in patients with recent stroke. However, when administered within 6 hours, NO donors might improve outcomes in both ischaemic and haemorrhagic stroke.
Interventions for Preventing Depression After Stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2009
Cerebrovascular Disease in Hypertension
Publisher: Elsevier
Date: 2007
Endovascular Thrombectomy with or without Intravenous Alteplase in Acute Stroke
Publisher: Massachusetts Medical Society
Date: 21-05-2020
The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial
Publisher: Elsevier BV
Date: 07-2023
Quality of Acute Care and Long-Term Quality of Life and Survival
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2017
DOI: 10.1161/STROKEAHA.116.015714
Abstract: Uncertainty exists over whether quality improvement strategies translate into better health-related quality of life (HRQoL) and survival after acute stroke. We aimed to determine the association of best practice recommended interventions and outcomes after stroke. Data are from the Australian Stroke Clinical Registry during 2010 to 2014. Multivariable regression was used to determine associations between 3 interventions: received acute stroke unit (ASU) care and in various combinations with prescribed antihypertensive medication at discharge, provision of a discharge care plan, and outcomes of survival and HRQoL (EuroQoL 5-dimensional questionnaire visual analogue scale) at 180 days, by stroke type. An assessment was also made of outcomes related to the number of processes patients received. There were 17 585 stroke admissions (median age 77 years, 47% female 81% managed in ASUs 80% ischemic stroke) from 42 hospitals (77% metropolitan) assessed. Cumulative benefits on outcomes related to the number of care processes received by patients. ASU care was associated with a reduced likelihood of death (hazard ratio, 0.49 95% confidence interval, 0.43–0.56) and better HRQoL (coefficient, 21.34 95% confidence interval, 15.50–27.18) within 180 days. For those discharged from hospital, receiving ASU+antihypertensive medication provided greater 180-day survival (hazard ratio, 0.45 95% confidence interval, 0.38–0.52) compared with ASU care alone (hazard ratio, 0.64 95% confidence interval, 0.54–0.76). HRQoL gains were greatest for patients with intracerebral hemorrhage who received care bundles involving discharge processes (range of increase, 11%–19%). Patients with stroke who receive best practice recommended hospital care have improved long-term survival and HRQoL.
Comparison of Fatal or Irreversible Events With Extended‐Duration Betrixaban Versus Standard Dose Enoxaparin in Acutely Ill Medical Patients: An APEX Trial Substudy
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2017
Abstract: Extended‐duration betrixaban showed a significant reduction in venous thromboembolism in the APEX trial (Acute Medically Ill VTE Prevention With Extended Duration Betrixaban Study). Given the variable clinical impact of different efficacy and safety events, one approach to assess net clinical outcomes is to include only those events that are either fatal or cause irreversible harm. This was a post hoc analysis of the APEX trial—a multicenter, double‐blind, randomized controlled trial comparing extended‐duration betrixaban versus standard‐of‐care enoxaparin. A composite of all fatal or irreversible safety (fatal bleeding or intracranial hemorrhage) and efficacy events (cardiopulmonary death, myocardial infarction, pulmonary embolism, and ischemic stroke) was evaluated in a time‐to‐first event analysis. In patients with positive D‐dimer results, betrixaban reduced fatal or irreversible events at 35 to 42 days (4.80% versus 3.54% hazard ratio, 0.73 absolute risk reduction, 1.26% number needed to treat, 79 [ P =0.033]) and at study end at 77 days (6.27% versus 4.36% hazard ratio, 0.70 absolute risk reduction, 1.91% number needed to treat, 52 [ P =0.005]) versus enoxaparin. In all patients, betrixaban reduced fatal or irreversible events at 35 to 42 days (4.08% versus 2.90% hazard ratio, 0.71 absolute risk reduction, 1.18% number needed to treat, 86 [ P =0.006]) and 77 days (5.17% versus 3.64% hazard ratio, 0.70 absolute risk reduction, 1.53% number needed to treat, 65 [ P =0.002]). Among hospitalized medically ill patients, extended‐duration betrixaban demonstrated an ≈30% reduction in fatal or irreversible ischemic or bleeding events compared with standard‐duration enoxaparin. A total of 65 patients would require treatment with betrixaban to prevent 1 fatal or irreversible event versus enoxaparin. URL : www.ClinicalTrials.gov . Unique identifier: NCT 01583218.
Intensive versus guideline‐recommended blood pressure reduction in acute lacunar stroke with intravenous thrombolysis therapy: The ENCHANTED trial
Publisher: Wiley
Date: 12-2021
DOI: 10.1111/ENE.14598
Abstract: This was an investigation of the differential effects of early intensive versus guideline‐recommended blood pressure (BP) lowering between lacunar and non‐lacunar acute ischaemic stroke (AIS) in the BP arm of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). In 1,632 participants classified as having definite or probable lacunar ( n = 454 [27.8%]) or non‐lacunar AIS according to pre‐specified definitions based upon clinical and adjudicated imaging findings, mean BP changes over days 0–7 were plotted, and systolic BP differences by treatment between subgroups were estimated in generalized linear models. Logistic regression models were used to estimate the BP treatment effects on 90‐day outcomes (primary, an ordinal shift of modified Rankin scale scores) across lacunar and non‐lacunar AIS after adjustment for baseline covariables. Most baseline characteristics, acute BP and other management differed between lacunar and non‐lacunar AIS, but mean systolic BP differences by treatment were comparable at each time point (all p interaction 0.12) and over 24 h post‐randomization (−5.5, 95% CI −6.5, −4.4 mmHg in lacunar AIS vs. −5.6, 95% CI −6.3, −4.8 mmHg in non‐lacunar AIS, p interaction = 0.93). The neutral effect of intensive BP lowering on functional outcome and the beneficial effect on intracranial haemorrhage were similar for the two subgroups (all p interaction 0.19). There were no differences in the treatment effect of early intensive versus guideline‐recommended BP lowering across lacunar and non‐lacunar AIS.
Withdrawal of active treatment after intracerebral haemorrhage in the INTERACT2 study
Publisher: Oxford University Press (OUP)
Date: 08-11-2016
Implementation of a Structured Guideline–Based Program for the Secondary Prevention of Ischemic Stroke in China
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2014
DOI: 10.1161/STROKEAHA.113.001424
Abstract: High rates of ischemic stroke and poor adherence to secondary prevention measures are observed in the Chinese population. We used a national, multicenter, cluster-randomized controlled trial in which 47 hospitals were randomized to either a structured care program group (n=23) or a usual care group (n=24). The structured care program consisted of a specialist-administered, guideline-recommended pharmaceutical treatment and a lifestyle modification algorithm associated with written and Internet-accessed educational material for patients for the secondary prevention of ischemic stroke. The primary efficacy outcome was the proportion of patients who adhered to the recommended measures at 12-month postdischarge. This trial is registered with ClinicalTrial.gov (NCT00664846). At 12 months, 1287 (72.1%) patients in the Standard Medical Management in Secondary Prevention of Ischemic Stroke in China (SMART) group and 1430 (72%) patients in the usual care group had completed the 12-month follow-up ( P =0.342). Compared with the usual care group, those in the SMART group showed higher adherence to statins (56% versus 33% P =0.006) but no difference in adherence to antiplatelet (81% versus 75% P =0.088), antihypertensive (67% versus 69% P =0.661), or diabetes mellitus drugs (73% versus 67% P =0.297). No significant difference in the composite end point (new-onset ischemic stroke, hemorrhagic stroke, acute coronary syndrome, and all-cause death) was observed (3.56% versus 3.59% P =0.921). The implementation of a program to improve adherence to secondary ischemic stroke prevention efforts in China is feasible, but these programs had only a limited impact on adherence and no impact on 1-year outcomes. Further development of a structured program to reduce vascular events after stroke is needed.
The Impact of Stroke on Unpaid Caregivers: Results from the Auckland Regional Community Stroke Study, 2002–2003
Publisher: S. Karger AG
Date: 2008
DOI: 10.1159/000131673
Abstract: i Background: /i Few studies have assessed the longitudinal impact of providing unpaid care for stroke survivors. We aimed to describe the positive and negative impact of providing unpaid care and to identify independent predictors of poor carer outcome. i Methods: /i The Auckland Regional Community Stroke study was a prospective population-based stroke incidence study conducted in Auckland, New Zealand, over a 12-month period in 2002–2003. Stroke survivors and their unpaid carers were assessed at 6 and 18 months after stroke onset using the Short Form 36 questionnaire and the Bakas Caregiving Outcomes Scale. i Results: /i Data were available from 167 stroke survivor–carer pairs at 6 months and 62 pairs at 18 months. Unpaid carers reported lower health-related quality of life at 6 months after stroke than their age- and sex-matched counterparts in the New Zealand population. The impact of providing care was predominantly negative however, approximately one third of the carers had improved relationships with the stroke survivor. No reliable predictors of carer burden were identified. i Conclusions: /i This study re-emphasises the heavy burden of stroke on unpaid carers but was unable to identify factors that predicted carers at the greatest risk of experiencing a poor outcome. Effective strategies are needed to reduce the burden of providing unpaid care.
Spectrum of primary intracerebral haemorrhage in Perth, Western Australia, 1989-90: Incidence and outcome
Publisher: BMJ
Date: 08-1994
Abstract: In a population based register of stroke (n = 536) compiled in Perth, Western Australia during an 18 month period in 1989-90, 60 cases (11%) of primary intracerebral haemorrhage were identified among 56 persons (52% men). The mean age of these patients was 68 (range 23-93) and 46 (77%) events were first ever strokes. The crude annual incidence was 35 per 100,000, with a peak in the eighth decade, and a male predominance. Deep and lobar haemorrhages each accounted for almost one third of all cases. The clinical presentations included sudden coma (12%), headache (8%), seizures (8%), and pure sensory-motor stroke (3%). Primary intracerebral haemorrhage was the first presentation of leukaemia in two cases (both fatal) and it followed an alcoholic binge in four cases. 55% had a history of hypertension. 16 (27%) patients, half of whom had a history of hypertension, were taking antiplatelet agents, and one patient was taking warfarin. There were only two confirmed cases of amyloid angiopathy. The overall 28 day case fatality was 35%, but this varied from 100% for haemorrhages in the brainstem to 22% for those in the basal ganglionic or thalamic region. Other predictors of early death were intraventricular extension of blood, volume of haematoma, mass effect, and coma and severe paresis at onset. Although based on small numbers, these data confirm the heterogeneous nature of primary intracerebral haemorrhage, but they also suggest a different clinical spectrum of this type of stroke in the community compared with the experience of specialist neurological units.
Stroke surveillance: population‐based estimates and projections for New Zealand
Publisher: Elsevier BV
Date: 12-2007
DOI: 10.1111/J.1753-6405.2007.00136.X
Abstract: To estimate the incidence, prevalence and mortality of stroke in New Zealand (NZ) in 2001, projected to 2011. Multistate lifetable models were constructed using smoothed rates of first-ever stroke incidence and relative risks of mortality estimated from the most recent Auckland Regional Community Stroke (ARCOS) Study. Estimates of the burden of stroke in NZ were calculated by applying rates output by the model to the 2001 population. Stroke incidence, prevalence and mortality were then projected to 2011, assuming similar trends in stroke incidence and case fatality to those estimated between the 1991/92 and 2002/03 studies. A total of 5,200 first-ever strokes were estimated to have occurred in NZ in 2001. Rates of stroke rose exponentially with increasing age and were 20% higher among males than females at most ages. Nevertheless, the lifetable risk of stroke was lower for males (16%) than females (18%). On average, males survived a year longer than females after a first-ever stroke (9.0 vs. 8.2 years). The incidence rates of first-ever stroke declined by approximately 1% per year between 1991 and 2003. The lifetable risk of stroke remained stable for females but increased for males (from 14% to 16%) over this period. Stroke prevalence also increased by approximately 1% per year, whereas stroke-related mortality fell by 4% per year. If these trends continue, approximately 6,000 first-ever strokes (2% annual increase), 45,000 stroke survivors (2% annual increase) and 2,000 stroke-related deaths (1% annual decline) are expected in 2011. Stroke mortality is falling faster than stroke incidence. This, together with population growth and ageing, will lead to a rising burden of stroke-related disability over the next decade.
Is Blood Pressure Lowering in the Very Elderly With Previous Stroke Associated With a Higher Risk of Adverse Events?
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 21-12-2021
Abstract: We investigated whether blood pressure lowering for secondary prevention is associated with a reduction in recurrent stroke risk and/or a higher risk of adverse events in very elderly compared with younger trial participants. This is a random effects meta‐analysis of randomized controlled trials of blood pressure lowering for secondary stroke prevention to evaluate age‐stratified ( , ≥80 years) risk of adverse events. Ovid‐MEDLINE was searched for trials between 1970 and 2020. Summary‐level data were acquired including outcomes of stroke, cardiovascular events, mortality, and adverse events. Seven trials were included comprising 38 596 participants, of whom 2336 (6.1%) were aged ≥80 years. There was an overall reduction in stroke risk in the intervention group compared with controls (risk ratio [RR], 0.90 [95% CI, 0.80, 0.98], I 2 =49%), and the magnitude of risk reduction did not differ by age subgroup ( , ≥80 years). There was no increase in the risk of hypotensive symptoms in the intervention group for patients aged years (RR, 1.19 [95% CI, 0.99], 1.44, I 2 =0%), but there was an increased risk in those ≥80 years (RR, 2.17 [95% CI, 1.22], 3.86, I 2 =0%). No increase was observed in the risk of falls, syncope, study withdrawal, or falls in either age subgroup. Very elderly people in secondary prevention trials of blood pressure lowering have an increased risk of hypotensive symptoms, but with no statistical increase in the risk of falls, syncope, or mortality. However, evidence is lacking for frail elderly with multiple comorbidities who may be more vulnerable to adverse effects of blood pressure lowering.
Protocol for process evaluation of a randomised controlled trial of family-led rehabilitation post stroke (ATTEND) in India
Publisher: BMJ
Date: 09-2016
DOI: 10.1136/BMJOPEN-2016-012027
Abstract: We are undertaking a randomised controlled trial (fAmily led rehabiliTaTion aftEr stroke in INDia, ATTEND) evaluating training a family carer to enable maximal rehabilitation of patients with stroke-related disability as a potentially affordable, culturally acceptable and effective intervention for use in India. A process evaluation is needed to understand how and why this complex intervention may be effective, and to capture important barriers and facilitators to its implementation. We describe the protocol for our process evaluation to encourage the development of in-process evaluation methodology and transparency in reporting. The realist and RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) frameworks informed the design. Mixed methods include semistructured interviews with health providers, patients and their carers, analysis of quantitative process data describing fidelity and dose of intervention, observations of trial set up and implementation, and the analysis of the cost data from the patients and their families perspective and programme budgets. These qualitative and quantitative data will be analysed iteratively prior to knowing the quantitative outcomes of the trial, and then triangulated with the results from the primary outcome evaluation. The process evaluation has received ethical approval for all sites in India. In low-income and middle-income countries, the available human capital can form an approach to reducing the evidence practice gap, compared with the high cost alternatives available in established market economies. This process evaluation will provide insights into how such a programme can be implemented in practice and brought to scale. Through local stakeholder engagement and dissemination of findings globally we hope to build on patient-centred, cost-effective and sustainable models of stroke rehabilitation. CTRI/2013/04/003557.
Effects of vitamin D supplementation on strength, physical performance, and falls in older persons: A systematic review
Publisher: Wiley
Date: 15-08-2003
DOI: 10.1046/J.1532-5415.2003.51405.X
Abstract: identify, appraise, and synthesize data from randomized, controlled trials of vitamin D supplementation in older people. A systematic review of trials identified from searches of databases, reference lists, review articles, and recent conference proceedings. Most studies performed in ambulatory setting. Older people (mean age=60). Vitamin D or vitamin D metabolites. Strength, physical performance, or falls. Thirteen trials involving 2,496 patients met this study's inclusion criteria. Most of the trials were small and had methodological problems. In 10 trials, there was no evidence that vitamin D or vitamin D metabolites had an effect on falls or physical function, but three trials showed a positive effect of vitamin D in combination with calcium. When available data from the four highest quality trials were pooled (n=1,317), there continued to be no evidence that vitamin D reduced the risk of falling (relative risk= 0.99, 95% confidence interval=0.89-1.11), although a single trial of vitamin D and calcium showed a positive effect. Although there is insufficient evidence that vitamin D supplementation alone improves physical performance in older people, some data suggest a benefit from vitamin D combined with calcium supplementation, but this requires confirmation in large, well-designed trials.
On the energy consumption of Pure and Slotted Aloha based RFID anti-collision protocols
Publisher: Elsevier BV
Date: 03-2009
Wake-up stroke: imaging-based diagnosis and recanalization therapy.
Publisher: Springer Science and Business Media LLC
Date: 15-07-2020
Increasing burden of stroke in China: A systematic review and meta-analysis of prevalence, incidence, mortality, and case fatality
Publisher: SAGE Publications
Date: 16-11-2023
DOI: 10.1177/17474930221135983
Abstract: The epidemiology of stroke is evolving in China as the population undergoes demographic, lifestyle, and economic transitions. An updated review is pertinent to providing feedback on current, and in planning future, prevention and management strategies. To identify high-quality epidemiological studies for quantifying the prevalence, incidence, mortality, and case fatality for stroke in China. A search was undertaken across a range of bibliographic databases on 30 November 2021 without time limitation. Assessments were made of the risk of bias of the included studies. The outcomes were synthesized using a random-effects model. Subgroup analysis and meta-regression models were used to define the source of heterogeneity. Of 9407 identified records, 26 population-based studies were included. Due to significant heterogeneity across the studies, the original range for crude rates of indices was wide. The pooled annual prevalence was 1329.5/100,000 (95% confidence interval (CI) 713.6–2131.9, p 0.001), incidence 442.1/100,000 (327.6–573.8, p 0.001), mortality 154.1/100,000 (52.6–308.8, I 2 = 100%, p 0.001), and case fatality 35.8% (26.1% to 46.1%, I 2 = 97%, p 0.001). The prevalence and incidence of stroke have increased, but stroke-related case fatality has declined in China over recent decades. There are significant regional and rural-urban differences in incidence rates. Despite improved public health policies and healthcare delivery, the burden of stroke remains high in China. Further coordinated efforts are required in prevention and community care to offset the likelihood of further expansion in the absolute number of stroke cases in this large population.
Psychosocial impact of screening for intracranial aneurysms in relatives with familial subarachnoid hemorrhage
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2005
DOI: 10.1161/01.STR.0000158906.79898.3A
Abstract: Background and Purpose— In families with ≥2 relatives with intracranial aneurysms (IAs), screening for IAs in asymptomatic first-degree relatives is often recommended. We assessed the long-term psychosocial impact of such screening. Methods— We identified all persons with IA (screen-positives) and matched them for age and sex with 2 controls without IA (screen-negatives) from hospital-based registers of familial IA. Persons underwent telephone interviews using questionnaires that covered the areas of psychosocial impact of screening, health-related quality of life (HRQoL), and mood. Data were compared between screen-positives and screen-negatives, and with reference populations. Results— Overall, 105 persons from 33 families with IA were included, of whom 35 were screen-positive and 70 were screen-negative. Of the screen-positives, 12 (44%) had reduced their work and 23 (66%) had experienced changes in ≥1 area of independence, self-esteem, future outlook, or personal relationships. In contrast, only 1 (2%) screen-negative person had stopped working and 12 (17%) others had experienced changes in their self-esteem, future outlook, or relationships. Screen-positives had lower HRQoL compared with screen-negatives and the reference population, whereas both screen groups had higher mean depression scores than the reference population. Despite these effects, only 3 persons regretted participating in screening. Conclusion— Although screening for IA is an important preventative strategy in high-risk in iduals, it is associated with considerable psychosocial effects, both positive and negative. Greater awareness of such outcomes, and appropriate intervention where necessary, would appear to be a necessary component of IA screening programs.
Pre-hospital transdermal glyceryl trinitrate in patients with stroke mimics: data from the RIGHT-2 randomised-controlled ambulance trial
Publisher: Springer Science and Business Media LLC
Date: 10-01-2022
DOI: 10.1186/S12873-021-00560-X
Abstract: Prehospital stroke trials will inevitably recruit patients with non-stroke conditions, so called stroke mimics. We undertook a pre-specified analysis to determine outcomes in patients with mimics in the second Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial (RIGHT-2). RIGHT-2 was a prospective, multicentre, paramedic-delivered, ambulance-based, sham-controlled, participant-and outcome-blinded, randomised-controlled trial of transdermal glyceryl trinitrate (GTN) in adults with ultra-acute presumed stroke in the UK. Final diagnosis (intracerebral haemorrhage, ischaemic stroke, transient ischaemic attack, mimic) was determined by the hospital investigator. This pre-specified subgroup analysis assessed the safety and efficacy of transdermal GTN (5 mg daily for 4 days) versus sham patch among stroke mimic patients. The primary outcome was the 7-level modified Rankin Scale (mRS) at 90 days. Among 1149 participants in RIGHT-2, 297 (26%) had a final diagnosis of mimic (GTN 134, sham 163). The mimic group were younger, mean age 67 (SD: 18) vs 75 (SD: 13) years, had a longer interval from symptom onset to randomisation, median 75 [95% CI: 47,126] vs 70 [95% CI:45,108] minutes, less atrial fibrillation and a lower systolic blood pressure and Face-Arm-Speech-Time tool score than the stroke group. The three most common mimic diagnoses were seizure (17%), migraine or primary headache disorder (17%) and functional disorders (14%). At 90 days, the GTN group had a better mRS score as compared to the sham group (adjusted common odds ratio 0.54 95% confidence intervals 0.34, 0.85 p = 0.008), a difference that persisted at 365 days. There was no difference in the proportion of patients who died in hospital, were discharged to a residential care facility, or suffered a serious adverse event. One-quarter of patients suspected by paramedics to have an ultra-acute stroke were subsequently diagnosed with a non-stroke condition. GTN was associated with unexplained improved functional outcome observed at 90 days and one year, a finding that may represent an undetected baseline imbalance, chance, or real efficacy. GTN was not associated with harm. This trial is registered with International Standard Randomised Controlled Trials Number ISRCTN 26986053 .
Perihematomal edema as predictor of outcome
Publisher: Scientific Scholar
Date: 2014
Association of Positive Airway Pressure With Cardiovascular Events and Death in Adults With Sleep Apnea
Publisher: American Medical Association (AMA)
Date: 11-07-2017
The emerging role of induced hypothermia in the management of acute stroke
Publisher: Elsevier BV
Date: 09-2002
Abstract: Current treatment of acute stroke remains unsatisfactory. This review presents experimental and clinical data which suggest that mild induced hypothermia could be a potent and practicable neuroprotective treatment of acute ischaemic stroke and intracerebral haemorrhage. Hypothermia, if proven to be safe, effective and widely practicable in patients with acute stroke, could have an enormous positive impact on reducing the burden of stroke worldwide. Critical issues that will need to be considered in a well designed randomised controlled trial of induced hypothermia in acute stroke patients are discussed.
Medical management of intracerebral haemorrhage
Publisher: BMJ
Date: 16-11-2017
Abstract: The global burden of intracerebral haemorrhage (ICH) is enormous. Developing evidence-based management strategies for ICH has been h ered by its erse aetiology, high case fatality and variable cooperative organisation of medical and surgical care. Progress is being made through the conduct of collaborative multicentre studies with the large s le sizes necessary to evaluate therapies with realistically modest treatment effects. This narrative review describes the major consequences of ICH and provides evidence-based recommendations to support decision-making in medical management.
Head position and cerebral blood flow in acute ischemic stroke patients: Protocol for the pilot phase, cluster randomized, Head Position in Acute Ischemic Stroke Trial (HeadPoST pilot)
Publisher: SAGE Publications
Date: 18-01-2016
Abstract: Few proven interventions exist for acute ischemic stroke (AIS), and most are expensive and restricted in applicability. Lying flat ‘head down’ positioning of AIS patients has been shown to increase by as much as 20%, mean cerebral blood flow velocities (CBFV) measured by transcranial Doppler (TCD) but whether this translates into clinical improvement is uncertain. To determine if the lying flat position increases mean CBFV in the affected territory as compared to the sitting up position in AIS patients. Head Position in Acute Ischemic Stroke Trial (HeadPoST pilot) is a cluster randomized (clusters being months), assessor-blinded end-point, phase IIb trial, where consecutive adults with anterior circulation AIS within 12 h of symptom onset are positioned to a randomized position for 48 h with TCD performed serially. Primary outcome is mean CBFV on TCD at 1 and 24 h after positioning. Secondary outcomes include: serious adverse events, neurological impairment at seven days, and death and disability at 90 days. Assuming an increase of 8.3 (SD 11.4) cm/s in average of mean CBFV when tilted from 30° to 0°, 46 clusters are required (92 patients in total) to detect a 20% increase of mean CBFV with 90% power and 5% level of significance. HeadPoST pilot is a cluster randomized multicenter clinical trial investigating the effect of head positioning on mean CBFV in anterior circulation AIS.
Long-term management of blood pressure after stroke
Publisher: BMJ
Date: 10-2002
J-shape relation of blood pressure reduction and outcome in acute intracerebral hemorrhage: A pooled analysis of INTERACT2 and ATACH-II individual participant data
Publisher: SAGE Publications
Date: 05-01-2022
DOI: 10.1177/17474930211064076
Abstract: The aim of this study was to better define the shape of association between the degree (“magnitude”) of early ( 1 h) reduction in systolic blood pressure (SBP) and outcomes in patients with acute intracerebral hemorrhage (ICH) through pooled analysis of the second Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2) and second Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH-II) datasets. Association of the continuous magnitude of SBP reduction described using cubic splines and an ordinal measure of the functional outcome on the modified Rankin scale (mRS) scores at 90 days were analyzed in generalized linear mixed models. Models were adjusted for achieved (mean) and variability (standard deviation, SD) of SBP between 1 and 24 h, various baseline covariates, and trial as a random effect. Among 3796 patients (mean age 63.1 (SD = 13.0) years female 37.4%), with a mean magnitude ( 1 h) of SBP reduction of 28.5 (22.8) mmHg, those with larger magnitude were more often non-Asian and female, had higher baseline SBP, received multiple blood pressure (BP) lowering agents, and achieved lower SBP levels in 1–24 h. Compared to those patients with no SBP reduction within 1 h (reference), the adjusted odds of unfavorable functional outcome, according to a shift in mRS scores, were lower for SBP reductions up to 60 mmHg with an inflection point between 32 and 46 mmHg, but significantly higher for SBP reductions 70 mmHg. Similar J-shape associations were evident across various time epochs across 24 h and consistent according to baseline hematoma volume and SBP and history of hypertension. A moderate degree of rapid SBP lowering is associated with improved functional outcome after ICH, but large SBP reductions over 1 h (e.g. from 200 to target 140 mmHg) were associated with reduction, or reversal, of any such benefit.
Trends in Ethnic Disparities in Stroke Incidence in Auckland, New Zealand, During 1981 to 2003
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2006
DOI: 10.1161/01.STR.0000195131.23077.85
Abstract: Background and Purpose— Although geographical variations in stroke rates are well documented, limited data exist on temporal trends in ethnic-specific stroke incidence. Methods— We assessed trends in ethnic-specific stroke rates using standard diagnostic criteria and community-wide surveillance procedures in Auckland, New Zealand (NZ) in 1981 to 1982, 1991 to 1992, and 2002 to 2003. Indirect and direct methods were used to adjust first-ever (incident) and total (attack) rates for changes in the structure of the population and reported with 95% CIs. Ethnicity was self-defined and categorized as “NZ/European,” “Maori,” “Pacific peoples,” and “Asian and other.” Results— Stroke attack (19% 95% CI, 11% to 26%) and incidence rates (19% 95% CI, 12% to 24%) declined significantly in NZ/Europeans from 1981 to 1982 to 2002 to 2003. These rates remained high or increased in other ethnic groups, particularly for Pacific peoples in whom stroke attack rates increased by 66% (95% CI 11% to 225%) over the periods. Some favorable downward trends in vascular risk factors, such as cigarette smoking, were counterbalanced by increasing age, body mass index, and diabetes in certain ethnic groups. Conclusions— Divergent trends in ethnic-specific stroke incidence and attack rates, and of associated risk factors, have occurred in Auckland over recent decades. The findings provide mixed views as to the future burden of stroke in populations undergoing similar lifestyle and structural changes.
Brain imaging abnormalities and outcome after acute ischaemic stroke: the ENCHANTED trial
Publisher: BMJ
Date: 14-10-2020
Abstract: To test the hypothesis that imaging signs of ‘brain frailty’ and acute ischaemia predict clinical outcomes and symptomatic intracranial haemorrhage (sICH) after thrombolysis for acute ischaemic stroke (AIS) in the alteplase dose arm of ENhanced Control of Hypertension ANd Thrombolysis strokE stuDy (ENCHANTED). Blinded assessors coded baseline images for acute ischaemic signs (presence, extent, swelling and attenuation of acute lesions and hyperattenuated arteries) and pre-existing changes (atrophy, leucoaraiosis and old ischaemic lesions). Logistic regression models assessed associations between imaging features and death at 7 and 90 days good recovery (modified Rankin Scale scores 0–2 at 90 days) and sICH. Data are reported with adjusted ORs and 95% CIs. 2916 patients (67±13 years, National Institutes of Health Stroke Scale 8 (5–14)) were included. Visible ischaemic lesions, severe hypoattenuation, large ischaemic lesion, swelling and hyperattenuated arteries were associated with 7-day death (OR (95% CI): 1.52 (1.06 to 2.18) 1.51 (1.01 to 2.18) 2.67 (1.52 to 4.71) 1.49 (1.03 to 2.14) and 2.17 (1.48 to 3.18)) and inversely with good outcome. Severe atrophy was inversely associated with 7-day death (0.52 (0.29 to 0.96)). Atrophy (1.52 (1.08 to 2.15)) and severe leucoaraiosis (1.74 (1.20 to 2.54)) were associated with 90-day death. Hyperattenuated arteries were associated with sICH (1.71 (1.01 to 2.89)). No imaging features modified the effect of alteplase dose. Non-expert-defined brain imaging signs of brain frailty and acute ischaemia contribute to the prognosis of thrombolysis-treated AIS patients for sICH and mortality. However, these imaging features showed no interaction with alteplase dose.
Effects of perindopril-based lowering of blood pressure on intracerebral hemorrhage related to amyloid angiopathy: the PROGRESS trial.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2009
DOI: 10.1161/STROKEAHA.109.563932
Abstract: Background and Purpose— Patients with cerebral amyloid angiopathy (CAA) are at high risk for intracerebral hemorrhage (ICH), but no effective prevention strategies have been established. The objective is to determine whether lowering of blood pressure (BP) provides protection for this high-risk patient group. Methods— This study is a subsidiary analysis of the PROGRESS trial—a randomized, placebo-controlled trial that established the beneficial effects of BP lowering in patients with cerebrovascular disease 6105 patients were randomly assigned to either active treatment (perindopril for all participants plus indapamide for those with neither an indication for nor a contraindication to a diuretic) or matching placebo. Outcomes were probable CAA-related ICH as defined by the Boston criteria, probable hypertension-related ICH, and unclassified ICH. Results— Over a mean follow-up of 3.9 years, 16 probable CAA-related ICH, 51 probable hypertension-related ICH, and 44 unclassified ICH occurred. Active treatment reduced the risk of CAA-related ICH by 77% (95% CI, 19%–93%), that of hypertension-related ICH by 46% (95% CI, 4%–69%), and that of unclassified ICH by 43% (95% CI, −5%–69%). There was no evidence of differences in the magnitude of the effects of treatment among different types of ICH ( P homogeneity=0.4). Conclusions— BP-lowering treatment is likely to provide protection against all types of ICH.
Off-Hour Admission and Outcomes in Patients with Acute Intracerebral Hemorrhage in the INTERACT2 Trial
Publisher: S. Karger AG
Date: 2015
DOI: 10.1159/000434690
Abstract: b i Background: /i /b Conflicting data exist of an association between off-hour (weekend, holiday, or night-time) hospital admission and adverse outcome in intracerebral hemorrhage (ICH). We determined the association between off-hour admissions and poor clinical outcome, and of any differential effect of early intensive blood pressure (BP) lowering treatment between off- and on-hour admissions, among participants of the Intensive BP Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). b i Methods: /i /b Subsidiary analysis of INTERACT2, a multinational, multicenter, clinical trial of patients with spontaneous ICH with elevated systolic BP, randomly assigned to intensive (target systolic BP mm Hg) or guideline-based ( mm Hg) BP management. Primary outcome was death or major disability (modified Rankin scale of 3-6) at 90 days. Off-hour admission was defined as night-time (4:30 p.m. to 8:30 a.m.) on weekdays, weekends (Saturday and Sunday), and public holidays in each participating country. b i Results: /i /b Of 2,794 patients with information on the primary outcome, 1,770 (63%) were admitted to study centers during off-hours. Off-hour admission was not associated with risk of poor outcome at 90 days (53% off-hour vs. 55% on-hour p = 0.49), even after adjustment for comorbid risk factors (odds ratio 0.92 95% CI 0.76-1.12). Consistency exists in the effects of intensive BP lowering between off- and on-hour admission (p = 0.85 for homogeneity). b i Conclusions: /i /b Off-hour admission was not associated with increased risks of death or major disability among trial protocol participants with acute ICH. Intensive BP lowering can provide similar treatment effect irrespective of admission hours.
Ambient Temperature and Severity of Intracerebral Haemorrhage: The INTERACT1 Study
Publisher: S. Karger AG
Date: 2014
DOI: 10.1159/000358304
Abstract: b i Background: /i /b Intracerebral haemorrhage (ICH) rates increase in winter months. We aimed to determine associations of ambient temperature with clinical severity and haematoma size in acute ICH among Chinese participants in the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT1). b i Methods: /i /b INTERACT1 was a randomised controlled trial of early intensive blood pressure lowering in 404 patients with acute ICH. Among 304 (79%) Chinese participants, data on ambient temperature (average, minimum, maximum and range) on the day of ICH onset obtained from the China Meteorological Data Sharing Service System were linked to measures of clinical severity: elevated National Institute of Health Stroke Scale score ( ), low Glasgow Coma Scale score ( ), and haematoma parameters at the time of presentation. Clinical outcomes were evaluated in logistic regression models, and haematoma volume (log transformed, with and without intraventricular haemorrhage, IVH) was evaluated in multivariable regression models. b i Results: /i /b No significant associations were evident between temperature parameters and clinical parameters and haematoma volume (with and without IVH), even after adjustment for key prognostic factors. b i Conclusions: /i /b No relationship was evident between ambient temperature and severity in acute ICH.
Readmissions after stroke: Linked data from the australian stroke clinical registry and hospital databases
Publisher: AMPCo
Date: 07-2015
DOI: 10.5694/MJA15.00021
Abstract: To assess the feasibility of linking a national clinical stroke registry with hospital admissions and emergency department data and to determine factors associated with hospital readmission after stroke or transient ischaemic attack (TIA) in Australia. Data from the Australian Stroke Clinical Registry (AuSCR) at a single Victorian hospital were linked to coded, routinely collected hospital datasets for admissions (Victorian Admitted Episodes Dataset) and emergency presentations (Victorian Emergency Minimum Dataset) in Victoria from 15 June 2009 to 31 December 2010, using stepwise deterministic data linkage techniques. Association of patient characteristics, social circumstances, processes of care and discharge outcomes with all-cause readmissions within 1 year from time of hospital discharge after an index admission for stroke or TIA. Of 788 patients registered in the AuSCR, 46% (359/781) were female, 83% (658/788) had a stroke, and the median age was 76 years. Data were successfully linked for 782 of these patients (99%). Within 1 year of their index stroke or TIA event, 42% of patients (291/685) were readmitted, with 12% (35/286) readmitted due to a stroke or TIA. Factors significantly associated with 1-year hospital readmission were two or more presentations to an emergency department before the index event (adjusted odds ratio [aOR], 1.57 95% CI, 1.02-2.43), higher Charlson comorbidity index score (aOR, 1.19 95% CI, 1.07-1.32) and diagnosis of TIA on the index admission (aOR, 2.15 95% CI, 1.30-3.56). Linking clinical registry data with routinely collected hospital data for stroke and TIA is feasible in Victoria. Using these linked data, we found that readmission to hospital is common in this patient group and is related to their comorbid conditions.
Triple Therapy Prevention of Recurrent Intracerebral Disease Events Trial: Rationale, design and progress
Publisher: SAGE Publications
Date: 07-01-2022
DOI: 10.1177/17474930211068671
Abstract: Patients who suffer intracerebral hemorrhage (ICH) are at very high risk of recurrent ICH and other serious cardiovascular events. A single-pill combination (SPC) of blood pressure (BP) lowering drugs offers a potentially powerful but simple strategy to optimize secondary prevention. The Triple Therapy Prevention of Recurrent Intracerebral Disease Events Trial (TRIDENT) aims to determine the effects of a novel SPC “Triple Pill,” three generic antihypertensive drugs with demonstrated efficacy and complementary mechanisms of action at half standard dose (telmisartan 20 mg, amlodipine 2.5 mg, and indapamide 1.25 mg), with placebo for the prevention of recurrent stroke, cardiovascular events, and cognitive impairment after ICH. An international, double-blind, placebo-controlled, randomized trial in adults with ICH and mild-moderate hypertension (systolic BP: 130–160 mmHg), who are not taking any Triple Pill component drug at greater than half-dose. A total of 1500 randomized patients provide 90% power to detect a hazard ratio of 0.5, over an average follow-up of 3 years, according to a total primary event rate (any stroke) of 12% in the control arm and other assumptions. Secondary outcomes include recurrent ICH, cardiovascular events, and safety. Recruitment started 28 September 2017. Up to 31 October 2021, 821 patients were randomized at 54 active sites in 10 countries. Triple Pill adherence after 30 months is 86%. The required s le size should be achieved by 2024. Low-dose Triple Pill BP lowering could improve long-term outcome from ICH.
The cardiac MRI substudy to ongoing telmisartan alone and in combination with ramipril global endpoint trial/telmisartan randomized assessment study in ACE-intolerant subjects with cardiovascular dise
Publisher: Springer Science and Business Media LLC
Date: 04-04-2009
DOI: 10.1007/S00392-009-0014-4
Abstract: The ONTARGET and TRANSCEND clinical trials were designed to investigate the cardioprotective effects of telmisartan 80 mg and ramipril 10 mg, alone and in combination, in patients at high risk of cardiovascular disease. Cardiac MRI enables investigation of mechanistic effects of these agents on cardiac structural and functional variables. Here, we report the design, analysis protocol, reproducibility and relevant quality control procedures, and baseline patient characteristics of the ONTARGET/TRANSCEND cardiac MRI substudy. MRI was undertaken in 330 subjects enrolled in ONTARGET, and 38 subjects in TRANSCEND, across eight centers in six countries. Analyses were performed by two independent analysts using guide-point modeling. Cases with discrepancies in LV mass (LVM) of >5% were independently reanalyzed. Cases with discrepancies in end-diastolic volume (EDV) of >5%, or end-systolic volume (ESV) of >12%, were then reconciled by consensus. Baseline characteristics were broadly similar to the main ONTARGET/TRANSCEND trials, except for a higher frequency of coronary artery disease and Asian ethnicity in the substudy. Reproducibility of MRI analyses (mean +/- SD) were 2.8 +/- 3.7 ml in EDV, -0.3 +/- 3.6 ml in ESV, 3.1 +/- 3.3 ml in SV, 1.1 +/- 1.8% in EF, and 0.4 +/- 4.5 g in LVM. Subgroup analyses revealed increased ESV and LVM, and reduced EF, in subjects with a history of either coronary artery disease or myocardial infarction. The ONTARGET/TRANSCEND cardiac MRI substudy protocol provides for a reliable assessment of the effects of telmisartan and ramipril, alone and in combination, on cardiac structural and functional parameters over a 2-year follow-up period.
Stroke Care during the COVID-19 Pandemic: International Expert Panel Review
Publisher: S. Karger AG
Date: 2021
DOI: 10.1159/000514155
Abstract: b i Background: /i /b Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of stroke experts, assesses the rapidly growing research and personal experience with COVID-19 stroke and offers recommendations for stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care inpatient intensive or stroke units posthospitalization rehabilitation follow-up including at-risk family and community and multispecialty departmental developments in the allied professions. b i Summary: /i /b The severe acute respiratory syndrome coronavirus 2 uses spike proteins binding to tissue angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to COVID-19. Clinicians facing the many etiologies for stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are vasculitis, cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of acute stroke management remain in force, but COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending COVID-19 determination and also for those shown to be COVID-19 affected, strict infection control is needed at all times to reduce spread of infection and to protect healthcare staff, using the wealth of well-described methods. For COVID-19 patients with stroke, thrombolysis and thrombectomy should be continued, and the usual early management of hypertension applies, save that recent work suggests continuing ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic LMWH unless bleeding risk is high. COVID-19-related cardiomyopathy adds risk of cardioembolic stroke, where heparin or warfarin may be preferable, with experience accumulating with DOACs. As ever, arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related stroke also forces rehabilitation services to use protective precautions. As with all stroke patients, health workers should be aware of symptoms of depression, anxiety, insomnia, and/or distress developing in their patients and caregivers. Postdischarge outpatient care currently includes continued secondary prevention measures. Although hoping a COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges, stroke care teams will also overcome this one. b i Key Messages: /i /b Evidence-based stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced.
Progress in Stroke: Marking the 30-Year Anniversary of Cerebrovascular Diseases
Publisher: S. Karger AG
Date: 2021
DOI: 10.1159/000514399
Incidence and associations of hemiplegic shoulder pain poststroke: prospective population-based study.
Publisher: Elsevier BV
Date: 02-2015
Baseline Cognitive Function, Recurrent Stroke, and Risk of Dementia in Patients With Stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2013
DOI: 10.1161/STROKEAHA.111.680728
Abstract: To determine the interrelationships between baseline Mini-Mental State Examination (MMSE) score and risk of overall dementia, post-recurrent stroke dementia, and dementia without recurrent stroke among patients with a history of stroke. Prospective cohort study among participants enrolled in the Perindopril Protection Against Recurrent Stroke Study (PROGRESS) for whom baseline MMSE score was available. Baseline MMSE score was ided into 4 categories: 30, 29–27, 26–24, and . Participants were followed for incident dementia and recurrent stroke. Logistic regression models were used to examine the association between MMSE score and dementia. Of the 6080 participants included in this analysis, 2493 had an MMSE score of 30, 1768 had a score of 29–28, 1369 had a score of 26–24, and 450 had a score of . Average follow-up time was 3.8 years. There were 407 cases of dementia, 106 of which were preceded by a recurrent stroke. The risk of overall dementia increased with decreasing MMSE score. However, the impact of MMSE score on the risk of dementia without recurrent stroke was much stronger than the impact of MMSE score on the risk of post-recurrent stroke dementia. For those with MMSE score , the risk of dementia without recurrent stroke was 47.89 (95% confidence interval, 28.57–80.26), whereas the risk of post-recurrent stroke dementia was only 7.17 (95% confidence interval, 3.70–13.89). Higher MMSE scores were even less strongly associated with the risk of post-recurrent stroke dementia. Patients with stroke with low MMSE scores are at high risk of dementia over time, even in the absence of a recurrent stroke, and should therefore be followed closely for further cognitive decline.
Blood pressure lowering and prevention of dementia: an individual patient data meta-analysis
Publisher: Oxford University Press (OUP)
Date: 25-10-2022
DOI: 10.1093/EURHEARTJ/EHAC584
Abstract: Observational studies indicate U-shaped associations of blood pressure (BP) and incident dementia in older age, but randomized controlled trials of BP-lowering treatment show mixed results on this outcome in hypertensive patients. A pooled in idual participant data analysis of five seminal randomized double-blind placebo-controlled trials was undertaken to better define the effects of BP-lowering treatment for the prevention of dementia. Multilevel logistic regression was used to evaluate the treatment effect on incident dementia. Effect modification was assessed for key population characteristics including age, baseline systolic BP, sex, and presence of prior stroke. Mediation analysis was used to quantify the contribution of trial medication and changes in systolic and diastolic BP on risk of dementia. The total s le included 28 008 in iduals recruited from 20 countries. After a median follow-up of 4.3 years, there were 861 cases of incident dementia. Multilevel logistic regression reported an adjusted odds ratio 0.87 (95% confidence interval: 0.75, 0.99) in favour of antihypertensive treatment reducing risk of incident dementia with a mean BP lowering of 10/4 mmHg. Further multinomial regression taking account of death as a competing risk found similar results. There was no effect modification by age or sex. Mediation analysis confirmed the greater fall in BP in the actively treated group was associated with a greater reduction in dementia risk. The first single-stage in idual patient data meta-analysis from randomized double-blind placebo-controlled clinical trials provides evidence to support benefits of antihypertensive treatment in late-mid and later life to lower the risk of dementia. Questions remain as to the potential for additional BP lowering in those with already well-controlled hypertension and of antihypertensive treatment commenced earlier in the life-course to reduce the long-term risk of dementia. Class I evidence in favour of antihypertensive treatment reducing risk of incident dementia compared with placebo.
Medical management of acute intracerebral hemorrhage
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2009
Are Stroke Units Cost Effective? Evidence from a New Zealand Stroke Incidence and Population-Based Study
Publisher: SAGE Publications
Date: 20-10-2011
DOI: 10.1111/J.1747-4949.2011.00632.X
Abstract: Acute stroke units in hospitals are known to be more costly than standard care, but proponents claim that the health gains will justify the expense. Yet, despite widespread adoption of stroke units, the evidence on the cost effectiveness of stroke units has been mixed, due in part to differences in the pathway of care across hospitals. The purpose of this study is to compare costs and outcomes for patients admitted to a stroke unit with those admitted to a general ward. Data on 530 stroke sufferers from a large incidence study of stroke (the Auckland Regional Community Stroke Outcome Study) were used. Cost of health services, places of discharge were identified at one-, six- and 12 months post-stroke and were linked with long-term cost and survival five-years poststroke. A decision analytical model was developed, including the relationship between waiting time for discharge and probability of admission to stroke unit. Cost effectiveness was determined using a willingness to pay threshold of NZ$20000 (US$15 234). Regression analysis suggested that there were no significant differences between patients admitted to a stroke unit and a general ward. The incremental cost-utility ratio for the first-year was NZ$42 813/quality-adjusted life year (US$32 610/quality-adjusted life year), but fell substantially to NZ$6747/quality-adjusted life year (US$5139/quality-adjusted life year) when lifetime costs and outcomes were considered. Probabilistic and one-way sensitivity analysis suggests that the results are robust to areas of uncertainty or delays in the pathway of care. Stroke unit care was cost effective in Auckland, New Zealand.
A FeIII/Oxo Cubane Contained in an Octanuclear Complex ofT Symmetry That Is Stable Over Five Oxidation States
Publisher: Wiley
Date: 06-1999
DOI: 10.1002/(SICI)1521-3773(19990601)38:11<1632::AID-ANIE1632>3.0.CO;2-O
Cardiovascular and biochemical risk factors for incident dementia in the hypertension in the very elderly trial
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2009
FAmily-Led RehabiliTaTion aftEr Stroke in INDia: The ATTEND Pilot Study
Publisher: SAGE Publications
Date: 09-03-2015
DOI: 10.1111/IJS.12475
Abstract: The aim of this pilot study was to determine the feasibility of a multicenter, randomized, controlled trial in India of a family-led, trained caregiver-delivered, home-based rehabilitation intervention vs. routine care. A prospective, randomized (within seven-days of hospital admission), blinded outcome assessor, controlled trial of structured home-based rehabilitation delivered by trained and protocol-guided family caregivers (intervention) vs. routine care alone (control) was conducted in patients with residual disability. Key feasibility measures were recruitment, acceptance and adherence to assessment procedures, and follow-up of participants over six-months. CTRI/2014/10/005133. A total of 104 patients from the stroke unit at Christian Medical College, Ludhiana were recruited over nine-months. Recruitment was feasible and accepted by patients and their carers. Important observations were made regarding potential unblinding of the participants, contamination of therapy between the randomized groups, organization of home visits, and resources required for a multicenter study. The pilot study established the feasibility of conducting a large-scale study of family-led, trained caregiver-delivered, home-based stroke rehabilitation in a low resource setting. The main phase of the trial ‘ATTEND’ is currently underway in over 10 centers in India.
Low Ambient Temperature and Intracerebral Hemorrhage: The INTERACT2 Study
Publisher: Public Library of Science (PLoS)
Date: 09-02-2016
Intensive Blood Pressure Lowering in Intracerebral Hemorrhage
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2017
Continuous Positive Airway Pressure Treatment, Glycemia, and Diabetes Risk in Obstructive Sleep Apnea and Comorbid Cardiovascular Disease
Publisher: American Diabetes Association
Date: 14-04-2020
DOI: 10.2337/DC19-2006
Abstract: Despite evidence of a relationship among obstructive sleep apnea (OSA), metabolic dysregulation, and diabetes, it is uncertain whether OSA treatment can improve metabolic parameters. We sought to determine effects of long-term continuous positive airway pressure (CPAP) treatment on glycemic control and diabetes risk in patients with cardiovascular disease (CVD) and OSA. Blood, medical history, and personal data were collected in a substudy of 888 participants in the Sleep Apnea cardioVascular Endpoints (SAVE) trial in which patients with OSA and stable CVD were randomized to receive CPAP plus usual care, or usual care alone. Serum glucose and glycated hemoglobin A1c (HbA1c) were measured at baseline, 6 months, and 2 and 4 years and incident diabetes diagnoses recorded. Median follow-up was 4.3 years. In those with preexisting diabetes (n = 274), there was no significant difference between the CPAP and usual care groups in serum glucose, HbA1c, or antidiabetic medications during follow-up. There were also no significant between-group differences in participants with prediabetes (n = 452) or new diagnoses of diabetes. Interaction testing suggested that women with diabetes did poorly in the usual care group, while their counterparts on CPAP therapy remained stable. Among patients with established CVD and OSA, we found no evidence that CPAP therapy over several years affects glycemic control in those with diabetes or prediabetes or diabetes risk over standard-of-care treatment. The potential differential effect according to sex deserves further investigation.
Effect of intensive structured care on individual blood pressure targets in primary care: multicentre randomised controlled trial
Publisher: BMJ
Date: 20-11-2012
DOI: 10.1136/BMJ.E7156
Systemic Inflammation, Endothelial Dysfunction, Dietary Fatty Acids and Micronutrients as Risk Factors for Stroke: A Selective Review
Publisher: S. Karger AG
Date: 2002
DOI: 10.1159/000057846
Abstract: As medicine moves into the 21st century, with added pressures of increasing costs and limited resources, successful reduction of the impact of stroke on the population will require shifting our emphasis away from treating end stages of generalized atherosclerosis and other underlying diseases to prevention of these diseases. However, before any potential interventions can be promoted with confidence, more needs to be known about the specific causes of stroke subtypes in various populations, especially potentially modifiable risk factors. In this selective review, we appraise current evidence on some markers of systemic inflammation (C-reactive protein), endothelial dysfunction (homocysteine, von Willebrand factor), dietary fatty acids and micronutrients as risk factors for stroke. Although a great deal of research into the role of these risk factors in cardiovascular diseases has been undertaken, little reliable information is available on their role in stroke, especially in the elderly. Evaluation of plasma fatty acids and specific antioxidants and micronutrients as well as markers of systemic inflammation, endothelial dysfunction (including C-reactive protein, homocysteine levels, von Willebrand factor, and paraoxonase activity) may prove to be valuable in the future determination of the risk of stroke.
Antihypertensive treatment decreases arterial stiffness at night but not during the day. Results from the Hypertension in the Very Elderly Trial
Publisher: Informa UK Limited
Date: 22-08-2016
DOI: 10.1080/08037051.2016.1219222
Abstract: The main Hypertension in the Very Elderly Trial (HYVET) demonstrated a very marked reduction in cardiovascular events by treating hypertensive participants 80 years or older with a low dose, sustained release prescription of indapamide (indapamide SR, 1.5 mg) to which was added a low dose of an angiotensin converting enzyme inhibitor in two-thirds of cases (perindopril 2-4 mg). This report from the ambulatory blood pressure sub-study investigates whether changes in arterial stiffness and ambulatory blood pressure (BP) could both explain the benefits observed in the main trial. A total of 139 participants were randomized to placebo [67] and to active treatment [72] and had both day and night observations of BP and arterial stiffness as determined from the Q wave Korotkoff diastolic (QKD) interval. The QKD interval was 5.6 ms longer (p = 0.017) in the actively treated group at night than in the placebo group. This was not true for the more numerous daytime readings so that 24-h results were similar in the two groups. The QKD interval remained longer at night in the actively treated group even when adjusted for systolic pressure, heart rate and height. The reduced arterial stiffness at night may partly explain the marked benefits observed in the main trial.
Statistical analysis plan for the family-led rehabilitation after stroke in India (ATTEND) trial: A multicenter randomized controlled trial of a new model of stroke rehabilitation compared to usual ca
Publisher: SAGE Publications
Date: 22-10-2016
Abstract: In low- and middle-income countries, few patients receive organized rehabilitation after stroke, yet the burden of chronic diseases such as stroke is increasing in these countries. Affordable models of effective rehabilitation could have a major impact. The ATTEND trial is evaluating a family-led caregiver delivered rehabilitation program after stroke. To publish the detailed statistical analysis plan for the ATTEND trial prior to trial unblinding. Based upon the published registration and protocol, the blinded steering committee and management team, led by the trial statistician, have developed a statistical analysis plan. The plan has been informed by the chosen outcome measures, the data collection forms and knowledge of key baseline data. The resulting statistical analysis plan is consistent with best practice and will allow open and transparent reporting. Publication of the trial statistical analysis plan reduces potential bias in trial reporting, and clearly outlines pre-specified analyses. India CTRI/2013/04/003557 Australian New Zealand Clinical Trials Registry ACTRN1261000078752 Universal Trial Number U1111-1138-6707.
Statistical analysis plan of the head position in acute ischemic stroke trial pilot (HEADPOST pilot)
Publisher: SAGE Publications
Date: 14-10-2017
Abstract: The HEADPOST Pilot is a proof-of-concept, open, prospective, multicenter, international, cluster randomized, phase IIb controlled trial, with masked outcome assessment. The trial will test if lying flat head position initiated in patients within 12 h of onset of acute ischemic stroke involving the anterior circulation increases cerebral blood flow in the middle cerebral arteries, as measured by transcranial Doppler. The study will also assess the safety and feasibility of patients lying flat for ≥24 h. The trial was conducted in centers in three countries, with ability to perform early transcranial Doppler. A feature of this trial was that patients were randomized to a certain position according to the month of admission to hospital. To outline in detail the predetermined statistical analysis plan for HEADPOST Pilot study. All data collected by participating researchers will be reviewed and formally assessed. Information pertaining to the baseline characteristics of patients, their process of care, and the delivery of treatments will be classified, and for each item, appropriate descriptive statistical analyses are planned with comparisons made between randomized groups. For the outcomes, statistical comparisons to be made between groups are planned and described. This statistical analysis plan was developed for the analysis of the results of the HEADPOST Pilot study to be transparent, available, verifiable, and predetermined before data lock. We have developed a statistical analysis plan for the HEADPOST Pilot study which is to be followed to avoid analysis bias arising from prior knowledge of the study findings. The study is registered under HEADPOST-Pilot, ClinicalTrials.gov Identifier NCT01706094.
Twelve-Month Clinical and Quality-of-Life Outcomes in the Interventional Management of Stroke III Trial
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2015
DOI: 10.1161/STROKEAHA.115.009180
Abstract: Randomized trials have indicated a benefit for endovascular therapy in appropriately selected stroke patients at 3 months, but data regarding outcomes at 12 months are currently lacking. We compared functional and quality-of-life outcomes at 12 months overall and by stroke severity in stroke patients treated with intravenous tissue-type plasminogen activator followed by endovascular treatment as compared with intravenous tissue-type plasminogen activator alone in the Interventional Management of Stroke III Trial. The key outcome measures were a modified Rankin Scale score ≤2 (functional independence) and the Euro-QoL EQ-5D, a health-related quality-of-life measure. 656 subjects with moderate-to-severe stroke (National Institutes of Health Stroke Scale ≥8) were enrolled at 58 centers in the United States (41 sites), Canada (7), Australia (4), and Europe (6). There was an interaction between treatment group and stroke severity in the repeated measures analysis of modified Rankin Scale ≤2 outcome ( P =0.039). In the 204 participants with severe stroke (National Institutes of Health Stroke Scale ≥20), a greater proportion of the endovascular group had a modified Rankin Scale ≤2 (32.5%) at 12 months as compared with the intravenous tissue-type plasminogen activator group (18.6%, P =0.037) no difference was seen for the 452 participants with moderately severe strokes (55.6% versus 57.7%). In participants with severe stroke, the endovascular group had 35.2 (95% confidence interval: 2.1, 73.3) more quality-adjusted-days over 12 months as compared with intravenous tissue-type plasminogen activator alone. Endovascular therapy improves functional outcome and health-related quality-of-life at 12 months after severe ischemic stroke. URL: www.clinicaltrials.gov . Unique identifier: NCT00359424.
Standards for Detecting, Interpreting, and Reporting Noncontrast Computed Tomographic Markers of Intracerebral Hemorrhage Expansion
Publisher: Wiley
Date: 24-08-2019
DOI: 10.1002/ANA.25563
Abstract: Significant hematoma expansion (HE) affects one-fifth of people within 24 hours after acute intracerebral hemorrhage (ICH), and its prevention is an appealing treatment target. Although the computed tomography (CT)-angiography spot sign predicts HE, only a minority of ICH patients receive contrast injection. Conversely, noncontrast CT (NCCT) is used to diagnose nearly all ICH, so NCCT markers represent a widely available alternative for prediction of HE. However, different NCCT signs describe similar features, with lack of consensus on the optimal image acquisition protocol, assessment, terminology, and diagnostic criteria. In this review, we propose practical guidelines for detecting, interpreting, and reporting NCCT predictors of HE. ANN NEUROL 2019 :480-492.
Low-Dose vs Standard-Dose Alteplase in Acute Lacunar Ischemic Stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 16-03-2021
DOI: 10.1212/WNL.0000000000011598
Abstract: To determine any differential efficacy and safety of low- vs standard-dose IV alteplase for lacunar vs nonlacunar acute ischemic stroke (AIS), we performed post hoc analyzes from the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED) alteplase dose arm. In a cohort of 3,297 ENCHANTED participants, we identified those with lacunar or nonlacunar AIS with different levels of confidence (definite/according to prespecified definitions based on clinical and adjudicated imaging findings. Logistic regression models were used to determine associations of lacunar AIS with 90-day outcomes (primary, modified Rankin Scale [mRS] scores 2–6 secondary, other mRS scores, intracerebral hemorrhage [ICH], and early neurologic deterioration or death) and treatment effects of low- vs standard-dose alteplase across lacunar and nonlacunar AIS with adjustment for baseline covariables. Of 2,588 participants with available imaging and clinical data, we classified cases as definite robable lacunar (n = 490) or nonlacunar AIS (n = 2,098) for primary analyses. Regardless of alteplase dose received, lacunar AIS participants had favorable functional (mRS 2–6, adjusted odds ratio [95% confidence interval] 0.60 [0.47–0.77]) and other clinical or safety outcomes compared to participants with nonlacunar AIS. Low-dose alteplase (versus standard) had no differential effect on functional outcomes (mRS 2–6, 1.04 [0.87–1.24]) but reduced the risk of symptomatic ICH in all included participants. There were no differential treatment effects of low- vs standard-dose alteplase on all outcomes across lacunar and nonlacunar AIS (all p interaction ≥0.07). We found no evidence from the ENCHANTED trial that low-dose alteplase had any advantages over standard dose for definite robable lacunar AIS. This study provides Class II evidence that for patients with lacunar AIS, low-dose alteplase had no additional benefit or safety over standard-dose alteplase. Clinicaltrials.gov identifier NCT01422616.
Hemiplegic Shoulder Pain Reduces Quality of Life after Acute Stroke: A Prospective Population-Based Study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2016
The second randomized controlled ENhanced Control of Hypertension ANd Thrombectomy strokE stuDy (ENCHANTED2): Protocol and progress
Publisher: SAGE Publications
Date: 24-08-2022
DOI: 10.1177/17474930221120345
Abstract: Uncertainty exists over the optimal level of blood pressure (BP) after mechanical thrombectomy (MT) for acute ischemic stroke (AIS). We aim to determine the effectiveness and safety of intensive BP-lowering following MT reperfusion of large-vessel occlusion (LVO)-related AIS. The second ENhanced Control of Hypertension ANd Thrombolysis strokE stuDy (ENCHANTED2) is an investigator-initiated, multicenter, prospective, randomized, open, blinded-endpoint (PROBE) trial of intensive systolic BP (SBP) control in reperfused (extended treatment in cerebral infarction (eTICI) classification 2b/2c/3) LVO-AIS patients with persistent hypertension (SBP ⩾ 140 mmHg) at 60+ sites in China, and Australia and the United Kingdom. Eligible patients are centrally randomly allocated to more- (target SBP ⩽ 120 mmHg within 1 h) or less-intensive (target SBP 140–180 mmHg) BP management, to be maintained for 72 h. Primary outcome is an ordinal shift analysis of scores on the modified Rankin scale (mRS) at 90 days. S le size of 2257 patients provides 90% power to detect a 6.5% absolute reduction in poor outcome from more-intensive BP-lowering using ordinal logistic regression. Recruitment started in China in July 2020. At a meeting of the independent Data and Safety Monitoring Board in March 2022 to review primary outcome data available for 347 patients, they recommended suspension of recruitment due to safety concerns in the more-intensive group which was implemented by the Trial Steering Committee (TSC) with 817 randomized patients only in China. The TSC then stopped recruitment after the safety concerns persisted on further review of the data in June 2022. The TSC will make a decision on restarting the trial with modification of the protocol when the results are made public. ENCHANTED2 will provide further randomized evidence on the role of intensive BP-lowering after reperfusion in MT-treated AIS patients. ClinicalTrials.gov NCT04140110 registered 25 October 2019.
Associations of Early Systolic Blood Pressure Control and Outcome After Thrombolysis-Eligible Acute Ischemic Stroke: Results From the ENCHANTED Study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2022
DOI: 10.1161/STROKEAHA.121.034580
Abstract: In thrombolysis-eligible patients with acute ischemic stroke, there is uncertainty over the most appropriate systolic blood pressure (SBP) lowering profile that provides an optimal balance of potential benefit (functional recovery) and harm (intracranial hemorrhage). We aimed to determine relationships of SBP parameters and outcomes in thrombolyzed acute ischemic stroke patients. Post hoc analyzes of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study), a partial-factorial trial of thrombolysis-eligible and treated acute ischemic stroke patients with high SBP (150–180 mm Hg) assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) alteplase and intensive (target SBP, 130–140 mm Hg) or guideline-recommended (target SBP mm Hg) treatment. All patients were followed up for functional status and serious adverse events to 90 days. Logistic regression models were used to analyze 3 SBP summary measures postrandomization: attained (mean), variability (SD) in 1–24 hours, and magnitude of reduction in 1 hour. The primary outcome was a favorable shift on the modified Rankin Scale. The key safety outcome was any intracranial hemorrhage. Among 4511 included participants (mean age 67 years, 38% female, 65% Asian) lower attained SBP and smaller SBP variability were associated with favorable shift on the modified Rankin Scale (per 10 mm Hg increase: odds ratio, 0.76 [95% CI, 0.71–0.82] P .001 and 0.86 [95% CI, 0.76–0.98] P =0.025) respectively, but not for magnitude of SBP reduction (0.98, [0.93–1.04] P =0.564). Odds of intracranial hemorrhage was associated with higher attained SBP and greater SBP variability (1.18 [1.06–1.31] P =0.002 and 1.34 [1.11–1.62] P =0.002) but not with magnitude of SBP reduction (1.05 [0.98–1.14] P =0.184). Attaining early and consistent low levels in SBP mm Hg, even as low as 110 to 120 mm Hg, over 24 hours is associated with better outcomes in thrombolyzed acute ischemic stroke patients. URL: www.clinicaltrials.gov Unique identifier: NCT01422616.
Zebrafish drug screening identifies candidate therapies for neuroprotection after spontaneous intracerebral haemorrhage
Publisher: The Company of Biologists
Date: 03-2022
DOI: 10.1242/DMM.049227
Abstract: Despite the global health burden, treatment of spontaneous intracerebral haemorrhage (ICH) is largely supportive, and translation of specific medical therapies has not been successful. Zebrafish larvae offer a unique platform for drug screening to rapidly identify neuroprotective compounds following ICH. We applied the Spectrum Collection library compounds to zebrafish larvae acutely after ICH to screen for decreased brain cell death and identified 150 successful drugs. Candidates were then evaluated for possible indications with other cardiovascular diseases. Six compounds were identified, including two angiotensin-converting enzyme inhibitors (ACE-Is). Ramipril and quinapril were further assessed to confirm a significant 55% reduction in brain cell death. Proteomic analysis revealed potential mechanisms of neuroprotection. Using the INTERACT2 clinical trial dataset, we demonstrated a significant reduction in the adjusted odds of an unfavourable shift in the modified Rankin scale at 90 days for patients receiving an ACE-I after ICH (versus no ACE-I odds ratio, 0.80 95% confidence interval, 0.68-0.95 P=0.009). The zebrafish larval model of spontaneous ICH can be used as a reliable drug screening platform and has identified therapeutics that may offer neuroprotection. This article has an associated First Person interview with the first author of the paper.
Brain Imaging Signs and Health-Related Quality of Life after Acute Ischemic Stroke: Analysis of ENCHANTED Alteplase Dose Arm
Publisher: S. Karger AG
Date: 2020
DOI: 10.1159/000509226
Abstract: b i Background and Purpose: /i /b The influence of specific brain lesions on health-related quality of life (HRQoL) after acute ischemic stroke (AIS) is uncertain. We aimed to identify imaging predictors of poor HRQoL in alteplase-treated participants of the alteplase dose arm of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). b i Methods: /i /b ENCHANTED was an international trial of low- versus standard-dose intravenous alteplase in AIS patients, with functional outcome (modified Rankin scale [mRS]) and HRQoL on the 5-dimension European Quality of Life Scale (EQ-5D) assessed at 90 days post-randomization. Brain images were analyzed centrally by trained assessors. Multivariable logistic regression was undertaken in the study population randomly ided (2:1) into training (development) and validation (performance) groups, with age (per 10-year increase), ethnicity, baseline National Institutes of Health Stroke Scale (NIHSS) score, diabetes mellitus, premorbid function (mRS score 0 or 1), and proxy respondent, forced into all models. Data are presented with odds ratios (ORs) and 95% confidence intervals (CIs). b i Results: /i /b Eight prediction models were developed and validated in 2,526 AIS patients (median age 67.5 years 38.4% female 61.7% Asian) with complete brain imaging and 90-day EQ-5D utility score data. The best performance model included acute ischemic changes in the right (OR 1.69, 95% CI: 1.24–2.29) and deep (OR 1.50, 95% CI: 1.03–2.19) middle cerebral artery (MCA) regions. Several background features of brain frailty – atrophy, white matter change, and old infarcts – were significantly associated with adverse physical but not emotional HRQoL domains. b i Conclusions: /i /b In thrombolysed AIS patients, right-sided and deep ischemia within the MCA territory predict poor overall HRQoL, whilst features of old cerebral ischemia are associated with reduced physical HRQoL.
Disability burden due to stroke in Western Australia: new insights from linked data sources
Publisher: SAGE Publications
Date: 06-07-2010
DOI: 10.1111/J.1747-4949.2010.00439.X
Abstract: The disability-adjusted life year index is used extensively to compare disease burden among diseases and locations, but difficulties remain in accurately estimating the nonfatal stroke burden in years lived with disability. To improve stroke-related years lived with disability estimates in Western Australia for 2000, by improving the accuracy of component inputs: nonfatal (28-day survivor) incidence, disease duration and disability (severity) weights. Nonfatal stroke incidence and the mortality difference between prevalent cases and the general population were estimated from linked hospital and mortality data using the Western Australian Data Linkage System. Dismod software used these inputs to model disease duration. Disability weights were estimated from population-based stroke survey data, using indirect health valuation methods and adjusting for prestroke disability. Years lived with disability were calculated from the three components. The annual age-standardised nonfatal incidence ( n = 1985) was higher ***In males (121/100 000) than females (96/100 000). The duration varied between 35.8 (females 15–24 years) and 3.4 years (males 85+ years). The mean pre-stroke-adjusted disability weight was higher at 4-months (0.38) than at 12-months (0.31). The age-standardised rate of nonfatal burden in males (302/100 000 95% CI 290–314) was significantly higher than that in females (250/100 000 95% CI 240–260). The nonfatal proportion of stroke burden (males 45% females 37%) was higher than estimated in previous studies. This study illustrates that previous reports most likely underestimated disability burden as a contributor to the total stroke burden in Australia. Methodological refinements will contribute to burden of disease studies elsewhere.
Revisiting cerebral thromboangiitis obliterans
Publisher: Elsevier BV
Date: 06-2012
DOI: 10.1016/J.JNS.2012.03.011
Abstract: We describe a 56-year-old patient with progressive cognitive decline in the context of heavy tobacco use and migraine, and imaging evidence of an occlusive terminal cerebral vasculopathy. The results of brain biopsy recapitulated the pathological features described by Lindenberg and Spatz in their classic 1939 treatise on cerebral thromboangiitis obliterans, or cerebral Buerger's disease. Although the condition is associated with heavy smoking, the identification of a hypercoagulable state in our patient suggests a multifactorial pathogenesis. The diagnosis of cerebral thromboangiitis obliterans in life is facilitated by modern neuroimaging and should prompt immediate cessation of smoking and a search for an underlying prothrombotic tendency.
Utility-Weighted Modified Rankin Scale Scores for the Assessment of Stroke Outcome
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2020
DOI: 10.1161/STROKEAHA.119.028523
Abstract: Patient-centered care prioritizes patient beliefs and values towards wellbeing. We aimed to map functional status (modified Rankin Scale [mRS] scores) and health-related quality of life on the European Quality of Life 5-dimensional questionnaire (EQ-5D) to derive utility-weighted (UW) stroke outcome measures and test their statistical properties and construct validity. UW-mRS scores were derived using linear regression, with mRS as a discrete ordinal explanatory response variable in 8 large international acute stroke trials. Linear regression models were used to validate UW-mRS scores by assessing differences in mean UW-mRS scores between the treatment groups of each trial. To explore the variability in EQ-5D between in idual mRS categories, we generated receiver operator characteristic curves for EQ-5D to differentiate between sequential mRS categories and misclassification matrix to classify in idual patients into a matched mRS category based on the closest UW-mRS value to their observed in idual EQ-5D value. Among 22 946 acute stroke patients, derived UW-mRS across mRS scores 0 to 6 were 0.96, 0.83, 0.72, 0.54, 0.22, −0.18, and 0, respectively. Both UW-mRS and ordinal mRS scores captured ergent treatment effects across all 8 acute stroke trials. The s le sizes required to detect the treatment effects using UW-mRS scores as a continuous variable were almost half that required in trials for a binary cut point on the mRS. Area under receiver operator characteristic curves based on EQ-5D utility values varied from 0.66 to 0.81. Misclassification matrix showed moderate agreement between actual and matched mRS scores (kappa, 0.68 [95% CI, 0.67–0.68]). Medical strategies that target avoiding dependency may provide maximum benefit in terms of poststroke health-related quality of life. Despite variable differences with mRS scores, the UW-mRS provides efficiency gains as a smaller s le size is required to detect a treatment effect in acute stroke trials through use of continuous scores. URL: www.clinicaltrials.gov Unique identifiers: NCT00226096, NCT00716079, NCT01422616, NCT02162017, NCT00120003, NCT02123875. URL: ctri.nic.in Unique identifier: CTRI/2013/04/003557. URL: www.isrctn.com Unique identifier: ISRCTN89712435.
Genome-Wide Association Study of Intracranial Aneurysms Confirms Role of Anril and SOX17 in Disease Risk
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2012
DOI: 10.1161/STROKEAHA.112.656397
Abstract: Genomewide association studies have identified novel genetic factors that contribute to intracranial aneurysm (IA) susceptibility. We sought to confirm previously reported loci, to identify novel risk factors, and to evaluate the contribution of these factors to familial and sporadic IA. We utilized 2 complementary s les, one recruited on the basis of a dense family history of IA (discovery s le 1: 388 IA cases and 397 controls) and the other without regard to family history (discovery s le 2: 1095 IA cases and 1286 controls). Imputation was used to generate a common set of single nucleotide polymorphisms (SNP) across s les, and a logistic regression model was used to test for association in each s le. Results from each s le were then combined in a metaanalysis. There was only modest overlap in the association results obtained in the 2 s les. In neither s le did results reach genomewide significance. However, the metaanalysis yielded genomewide significance for SNP on chromosome 9p ( CDKN2BAS rs6475606 P =3.6 × 10 −8 ) and provided further evidence to support the previously reported association of IA with SNP in SOX17 on chromosome 8q (rs1072737 P =8.7 × 10 −5 ). Analyses suggest that the effect of smoking acts multiplicatively with the SNP genotype, and smoking has a greater effect on risk than SNP genotype. In addition to replicating several previously reported loci, we provide further evidence that the association on chromosome 9p is attributable to variants in CDKN2BAS (also known as ANRIL , an antisense noncoding RNA).
Relationship between metamorphopsia and inner retinal microstructure following intravitreal ranibizumab injection for branch retinal vein occlusion
Publisher: Springer Science and Business Media LLC
Date: 24-02-2021
DOI: 10.1038/S41598-021-84038-7
Abstract: To evaluate the effects of intravitreal ranibizumab injection (IVR) on metamorphopsia in patients with branch retinal vein occlusion (BRVO), and to assess the relationship between metamorphopsia and inner retinal microstructure and other factors. Thirty-three treatment-naïve eyes of 33 patients with macular edema caused by BRVO with at least 12 months of follow-up were included. The degree of metamorphopsia was quantified using the M-CHARTS. Retinal microstructure was assessed with spectral-domain optical coherence tomography. Disorganization of the retinal inner layers (DRIL) at the first month after resolution of the macular edema (early DRIL) and at 12 months after treatment (after DRIL) was studied. Central retinal thickness (CRT), and status of the external limiting membrane as well as ellipsoid zone were also evaluated. IVR treatment significantly improved best-corrected visual acuity (BCVA) and CRT, but the mean metamorphopsia score did not improve even after 12 months. Post-treatment metamorphopsia scores showed a significant correlation with pre-treatment metamorphopsia scores ( P 0.005), the extent of early DRIL ( P 0.05) and after DRIL ( P 0.05), and the number of injections ( P 0.05). Multivariate analysis revealed that the post-treatment mean metamorphopsia score was significantly correlated with the pre-treatment mean metamorphopsia score ( P 0.05). IVR treatment significantly improved BCVA and CRT, but not metamorphopsia. Post-treatment metamorphopsia scores were significantly associated with pre-treatment metamorphopsia scores, the extent of DRIL, and the number of injections. Prognostic factor of metamorphopsia was the degree of pre-treatment metamorphopsia.
Rationale, Design, and Progress of the ENhanced Control of Hypertension ANd Thrombolysis Stroke Study (ENCHANTED) Trial: An International Multicenter 2 × 2 Quasi-Factorial Randomized Controlled Trial
Publisher: SAGE Publications
Date: 02-04-2015
DOI: 10.1111/IJS.12486
Abstract: Controversy exists over the optimal dose of intravenous (iv) recombinant tissue plasminogen activator (rt-PA) and degree of blood pressure (BP) control in acute ischaemic stroke (AIS). Asian studies suggest low-dose (0·6 mg/kg) is more efficacious than standard-dose (0·9 mg/kg) iv rt-PA, and guidelines recommend reducing systolic BP to mmHg before and mmHg after use of iv rt-PA, despite observational studies indicating better outcomes at much lower ( mmHg) systolic BP levels in this patient group. The study aims to assess in thrombolysis-eligible AIS patients whether: (i) low-dose (0·6 mg/kg body weight maximum 60 mg) iv rt-PA has non-inferior efficacy and lower risk of symptomatic intracerebral haemorrhage (sICH) compared to standard-dose (0·9 mg/kg body weight maximum 90 mg) iv rt-PA and (ii) early intensive BP lowering (systolic target 130–140 mmHg) has superior efficacy and lower risk of any ICH compared to guideline-recommended BP control (systolic target 180 mmHg). The ENhanced Control of Hypertension And Thrombolysis strokE stuDy (ENCHANTED) trial is an independent, 2 × 2 quasi-factorial, active-comparison, prospective, randomized, open blinded endpoint (PROBE), clinical trial that is evaluating Arm [A] ‘rt-PA dose’ and/or Arm [B] ‘BP control’, using central Internet randomization and data collection in patients fulfilling local criteria for thrombolysis and clinician uncertainty over the study treatments. The treatment arms will be analyzed separately. The primary study outcome in both trial Arms is death or disability according to the modified Rankin scale (mRS, scores 2–6) assessed at 90 days. Secondary outcomes include sICH, any ICH, a shift (‘improvement’) in function across mRS scores, separately on death and disability, early neurological deterioration, recurrent major vascular events, health-related quality of life, length of hospital stay, need for permanent residential care, and health care costs. Following launch of the trial in February 2012, the study has recruited more than 2500 patients across a global network of approximately 100 sites in 15 countries. The required s le sizes are 3300 for Arm [A] and 2300 for Arm [B], which will provide % power to detect non-inferiority of low-dose iv rt-PA and superiority of intensive BP lowering on the primary clinical outcome, respectively. Low-dose iv rt-PA and early intensive BP lowering could provide more affordable and safer use of thrombolysis treatment for patients with AIS worldwide.
Sleep for Stroke Management and Recovery Trial (Sleep SMART): Rationale and methods
Publisher: SAGE Publications
Date: 04-02-2020
Abstract: Obstructive sleep apnea is common among patients with acute ischemic stroke and is associated with reduced functional recovery and an increased risk for recurrent vascular events. The Sleep for Stroke Management and Recovery Trial (Sleep SMART) aims to determine whether automatically adjusting continuous positive airway pressure (aCPAP) treatment for obstructive sleep apnea improves clinical outcomes after acute ischemic stroke or high-risk transient ischemic attack. A total of 3062 randomized subjects for the prevention of recurrent serious vascular events, and among these, 1362 stroke survivors for the recovery outcome. Sleep SMART is a phase III, multicenter, prospective randomized, open, blinded outcome event assessed controlled trial. Adults with recent acute ischemic stroke/transient ischemic attack and no contraindication to aCPAP are screened for obstructive sleep apnea with a portable sleep apnea test. Subjects with confirmed obstructive sleep apnea but without predominant central sleep apnea proceed to a run-in night of aCPAP. Subjects with use (≥4 h) of aCPAP and without development of significant central apneas are randomized to aCPAP plus usual care or care-as-usual for six months. Telemedicine is used to monitor and facilitate aCPAP adherence remotely. Two separate primary outcomes: (1) the composite of recurrent acute ischemic stroke, acute coronary syndrome, and all-cause mortality (prevention) and (2) the modified Rankin scale scores (recovery) at six- and three-month post-randomization, respectively. Sleep SMART represents the first large trial to test whether aCPAP for obstructive sleep apnea after stroke/transient ischemic attack reduces recurrent vascular events or death, and improves functional recovery.
Endovascular Therapy after Intravenous t-PA versus t-PA Alone for Stroke
Publisher: Massachusetts Medical Society
Date: 07-03-2013
Mortality and Causes of Death in the Familial Intracranial Aneurysm Study
Publisher: SAGE Publications
Date: 29-08-2012
DOI: 10.1111/J.1747-4949.2012.00857.X
Abstract: Higher mortality for patients with aneurysmal subarachnoid haemorrhage has been reported. In families with intracranial aneurysms, we sought to determine whether mortality among subjects with intracranial aneurysm (affected) was higher and related to rupture, compared with unaffected family members. Subjects enrolled in the Familial Intracranial Aneurysm protocol were contacted yearly and their status was obtained. If reported to be deceased, the cause of death was verified by available records. A Cox proportional hazards model was utilized to compare mortality rates. Of the 2794 subjects, 1073 were affected and 1721 were unaffected. There were 8525 person-years of follow-up (mean 3·05 ± 1·73 years) and 85 deaths. Age at study entry for the affected (58·4 ±11·9 years) was significantly older ( P 0·0001) than for the unaffected (52·2 ± 16·1). After adjusting for age, the overall mortality rate for the affected subjects was not significantly different from that for the unaffected (Rate Ratio [RR] 1·26, 95% confidence interval 0·82–1·93, P = 0·292). There was a strong effect modification due to age. The mortality rate ratio of the affected to the unaffected who were ≤60 years of age was RR = 3·48 (95% confidence interval: 1·59–7·63, P = 0·002), the rate for the affected subjects who were ≥60 was less than the rate for the unaffected (RR = 0·69, 95% confidence interval: 0·404–1·19, P = 0·178). The affected who had ruptures had 2·62 times the mortality rate as those without ruptures (95% confidence interval 1·43–4·80, P = 0·002). The overall mortality was similar for the affected and unaffected subjects in this cohort. Among the affected only, those with ruptured intracranial aneurysm had a higher mortality rate than those without ruptured.
Twelve-Month Outcomes of the AFFINITY Trial of Fluoxetine for Functional Recovery After Acute Stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2021
DOI: 10.1161/STROKEAHA.120.033070
Abstract: The AFFINITY trial (Assessment of Fluoxetine in Stroke Recovery) reported that oral fluoxetine 20 mg daily for 6 months after acute stroke did not improve functional outcome and increased the risk of falls, bone fractures, and seizures. After trial medication was ceased at 6 months, survivors were followed to 12 months post-randomization. This preplanned secondary analysis aimed to determine any sustained or delayed effects of fluoxetine at 12 months post-randomization. AFFINITY was a randomized, parallel-group, double-blind, placebo-controlled trial in adults (n=1280) with a clinical diagnosis of stroke in the previous 2 to 15 days and persisting neurological deficit who were recruited at 43 hospital stroke units in Australia (n=29), New Zealand (4), and Vietnam (10) between 2013 and 2019. Participants were randomized to oral fluoxetine 20 mg once daily (n=642) or matching placebo (n=638) for 6 months and followed until 12 months after randomization. The primary outcome was function, measured by the modified Rankin Scale, at 6 months. Secondary outcomes for these analyses included measures of the modified Rankin Scale, mood, cognition, overall health status, fatigue, health-related quality of life, and safety at 12 months. Adherence to trial medication was for a mean 167 (SD 48) days and similar between randomized groups. At 12 months, the distribution of modified Rankin Scale categories was similar in the fluoxetine and placebo groups (adjusted common odds ratio, 0.93 [95% CI, 0.76–1.14] P =0.46). Compared with placebo, patients allocated fluoxetine had fewer recurrent ischemic strokes (14 [2.18%] versus 29 [4.55%] P =0.02), and no longer had significantly more falls (27 [4.21%] versus 15 [2.35%] P =0.08), bone fractures (23 [3.58%] versus 11 [1.72%] P =0.05), or seizures (11 [1.71%] versus 8 [1.25%] P =0.64) at 12 months. Fluoxetine 20 mg daily for 6 months after acute stroke had no delayed or sustained effect on functional outcome, falls, bone fractures, or seizures at 12 months poststroke. The lower rate of recurrent ischemic stroke in the fluoxetine group is most likely a chance finding. URL: www.anzctr.org.au/ Unique identifier: ACTRN12611000774921.
Screening for Fabry Disease in Young Strokes in the Australian Stroke Clinical Registry (AuSCR).
Publisher: Frontiers Media SA
Date: 24-11-2020
DOI: 10.3389/FNEUR.2020.596420
Abstract: Introduction: Fabry disease (FD) is an X-linked lysosomal storage disorder characterized by a deficiency or absence of alpha-galactosidase A (α-GAL A) enzyme, where stroke can be a serious complication. The aim of this study is to determine the feasibility of centralized screening for FD, among young stroke adults registered in the national Australian Stroke Clinical Registry (AuSCR). Methods: The study was conducted in young (age 18 – 55 years) survivors of acute stroke of unknown etiology registered in AuSCR at hospitals in Queensland, Tasmania, New South Wales, and Victoria during 2014 – 2015 and who, at the 3-month outcome assessment, agreed to be re-contacted for future research. Descriptive analyses of case identification from responses and specific enzyme and DNA sequencing analyses were conducted for α-galactosidase A (α-GLA) from dried blood spot (DBS) testing. Results: Of 326 AuSCR-identified patients invited to participate, 58 (18%) provided consent but six were subsequently unable to provide a blood s le and two later withdrew consent to use their data. Among the remaining 50 participants (median age 53 years [48 – 56 years] 47% female), 67% had experienced an acute ischemic stroke. All males ( n = 27) had an initial screen for α-GLA enzyme activity of whom seven with low enzyme levels had normal secondary α-GLA gene analysis. All females ( n = 23) had genetic analysis, with one shown to have a pathogenic c.352C& T p.(Arg118Cys) missense mutation of the α-GLA gene for FD. Conclusions: These findings provide logistical data for embedding a process of automated central stroke registry screening for an additional case-finding tool in FD.
Ten-Year Survival After First-Ever Stroke in the Perth Community Stroke Study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2003
DOI: 10.1161/01.STR.0000082382.42061.EE
Abstract: Background and Purpose— Very few studies have provided information regarding long-term prognosis after stroke. We aimed to determine the absolute and relative survival over 10 years among patients with first-ever stroke from a population-based study in Perth, Western Australia. Methods— For a 12-month period beginning February 1989, all in iduals with a suspected acute stroke or transient ischemic attack who were resident in a geographically defined and representative region of Perth, Western Australia, were registered prospectively and assessed according to standardized diagnostic criteria. Patients with a definite first-ever stroke were followed up prospectively at 4 months, 12 months, 5 years, and 10 years after the index event. Results— A total of 251 patients with first-ever stroke were registered, and 244 (97%) were followed up at 10 years, by which time 197 (79% 95% confidence interval [CI], 74 to 84) had died. The major causes of death were the direct effects of the initial stroke (27% 95% CI, 21 to 33) and cardiovascular disease (26% 95% CI, 20 to 32). Among 1-year survivors of stroke, the average annual case fatality was 4.8%, which was 2.3 (95% CI, 1.9 to 2.7) times greater than for the general population of the same age and sex. Conclusions— One in 5 patients with first-ever stroke survived to 10 years. The average annual case fatality was 4.8% between years 1 and 10 after stroke, which was twice that expected for the general population. Vascular disease is the major cause of death among long-term survivors of stroke.
Assuming one dose per day yields a similar estimate of medication adherence in patients with stroke: An exploratory analysis using linked registry data
Publisher: Wiley
Date: 23-07-2021
DOI: 10.1111/BCP.14468
Separating posterior-circulation stroke from vestibular neuritis with quantitative vestibular testing
Publisher: Elsevier BV
Date: 08-2020
Thrombolysis with alteplase after stroke: Extending outcomes
Publisher: Elsevier BV
Date: 08-2013
SLCO1B1 variants and statin-induced myopathy - A genomewide study
Publisher: Massachusetts Medical Society
Date: 21-08-2008
Combined utility of blood glucose and white blood cell in predicting outcome after acute ischemic stroke: The ENCHANTED trial
Publisher: Elsevier BV
Date: 11-2020
Oxygen desaturation and adverse outcomes in acute stroke: Secondary analysis of the HeadPoST study
Publisher: Elsevier BV
Date: 08-2021
DOI: 10.1016/J.CLINEURO.2021.106796
Abstract: Uncertainty exists over the prognostic significance of low arterial oxygen saturation (SaO Post-hoc analyzes of HeadPoST, a pragmatic cluster-crossover randomized trial of lying flat versus sitting up head positioning in 11,093 patients (age ≥18 years) with acute stroke at 114 hospitals in 9 countries during 2015-2016. Associations of the lowest recorded SaO There was an inverse J-shaped association between SaO Any change in SaO HeadPoST is registered at ClinicalTrials.gov (NCT02162017).
Clinical prognosis of FLAIR hyperintense arteries in ischaemic stroke patients: A systematic review and meta-analysis
Publisher: BMJ
Date: 26-03-2020
Abstract: We performed a systematic review and meta-analysis to determine the association of fluid-attenuated inversion recovery (FLAIR) hyperintense arteries (FLAIR-HAs) on brain MRI and prognosis after acute ischaemic stroke (AIS). We searched Medline, Embase and Cochrane Central Register of Controlled Trials for studies reporting clinical or imaging outcomes with presence of FLAIR-HAs after AIS. Two researchers independently assessed eligibility of retrieved studies and extracted data, including from the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). Outcomes were unfavourable functional outcome (primary, modified Rankin scale scores 3–6 or 2–6), death, intermediate clinical and imaging outcomes. We performed subgroup analyses by treatment or types of FLAIR-HAs defined by location (at proximal/distal middle cerebral artery (MCA), within/beyond diffusion-weighted imaging (DWI) lesion) or extent. We included 36 cohort studies (33 prospectively collected) involving 3577 patients. FLAIR-HAs were not associated with functional outcome overall (pooled risk ratio 0.87, 95% CI 0.71 to 1.06), but were significantly associated with better outcome in those receiving endovascular therapy (0.56, 95% CI 0.41 to 0.75). Contrary to FLAIR-HAs at proximal MCA or within DWI lesions, FLAIR-HAs beyond DWI lesions were associated with better outcome (0.67, 95% CI 0.57 to 0.79). FLAIR-HAs favoured recanalisation (1.21, 95% CI 1.06 to 1.38) with increased risk of intracerebral haemorrhage (2.07, 95% CI 1.37 to 3.13) and early neurological deterioration (1.93, 95% CI 1.30 to 2.85). FLAIR-HAs were not associated with functional outcome overall but were associated with outcome after endovascular therapy for AIS. FLAIR-HAs were also associated with early recanalisation or haemorrhagic complications, and early neurologic deterioration. CRD42019131168.
Editorial
Publisher: SAGE Publications
Date: 02-2008
The influence of design and definition on the proportion of general epilepsy cohorts with remission and intractability
Publisher: S. Karger AG
Date: 2011
DOI: 10.1159/000327497
Abstract: Remission while on anti-epileptic drug (AED) therapy and remission off AED are the only prognostic criteria defined by the International League against Epilepsy (ILAE), defining remission as 5 seizure-free years. Prognosis studies in epilepsy have investigated other prognostic categories using different designs and definitions. This systematic review explores factors that explain discrepancies in the proportion of patients reported with commonly studied prognostic categories in general epilepsy cohorts. Thirty publications (reporting 37 studies) were included. The outcome categories were classified as immediate remission (5 studies), remission off medication (7 studies), remission on or off medication (15 studies), intractability (9 studies) and no remission after relapse (1 study). The findings show the importance of qualifying estimates specifically by how they were defined in each study, study design, setting and patient population as these have implications for patient management and counselling. The ILAE should define the outcome measures and terminology to which researchers should be required to adhere in subsequent updates of their guidelines on research related to remission and intractability.
Interventions for treating depression after stroke
Publisher: Wiley
Date: 08-10-2008
Effects of blood pressure lowering with perindopril and indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease
Publisher: American Medical Association (AMA)
Date: 12-05-2003
Fresh Insights Into Variable Mortality From Subarachnoid Hemorrhage Across Regions of Finland
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 29-09-2023
Course and impact of sleep disturbance in newly diagnosed epilepsy: A prospective registry study
Publisher: Elsevier BV
Date: 08-2020
Falls After Stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2008
DOI: 10.1161/STROKEAHA.107.509885
Abstract: Background and Purpose— Falls are an important issue in older people. We aimed to determine the incidence, circumstances, and predictors of falls in patients with recent acute stroke. Methods— The Auckland Regional Community Stroke (ARCOS) study was a prospective population-based stroke incidence study conducted in Auckland, New Zealand (NZ) during 2002 to 2003. Among 6-month survivors, the location and consequences of any falls were ascertained by self-report as part of a structured interview. Multivariable logistic regression was used to establish associations between risk factors and “any” and “injurious” falls. Results— Of 1104 stroke survivors who completed an interview, 407 (37%) reported at least 1 fall, 151 (37% of fallers, 14% of stroke survivors) sustained an injury that required medical treatment, and 31 (8% of fallers, 3% of stroke survivors) sustained a fracture. The majority of falls occurred indoors at home. Independent factors associated with falls were depressive symptoms, disability, previous falls, and older age. For injurious falls, the positively associated factors were female sex and NZ/European ethnicity and dependence before the stroke, whereas higher levels of activity and normal cognition were negatively associated factors. Conclusions— Falls are common after stroke, and their predictive factors are similar to those for older people in general. Falls prevention programs require implementation in stroke services.
Perindopril-based blood pressure-lowering reduces major vascular events in patients with atrial fibrillation and prior stroke or transient ischemic attack.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2005
DOI: 10.1161/01.STR.0000181115.59173.42
Abstract: Background and Purpose— Patients with atrial fibrillation have a high risk of stroke and other vascular events even if anticoagulated. The primary objective here is to determine whether routine blood pressure–lowering provides additional protection for this high-risk patient group. Methods— This study was a subsidiary analysis of the Perindopril Protection Against Recurrent Stroke Study (PROGRESS)—a randomized, placebo-controlled trial that established the beneficial effects of blood pressure–lowering in a heterogeneous group of patients with cerebrovascular disease. A total of 6105 patients were randomly assigned to either active treatment (2 to 4 mg perindopril for all participants plus 2.0 to 2.5 mg indapamide for those without an indication for or a contraindication to a diuretic) or matching placebo(s). Outcomes are total major vascular events, cause-specific vascular outcomes, and death from any cause. Results— There were 476 patients with atrial fibrillation at baseline, of whom 51% were taking anticoagulants. In these patients, active treatment lowered mean blood pressure by 7.3/3.4 mm Hg and was associated with a 38% (95% confidence interval [CI], 6 to 59) reduction in major vascular events and 34% (95% CI, −13 to 61) reduction in stroke. The benefits of blood pressure–lowering in patients with atrial fibrillation were achieved irrespective of the use of anticoagulant therapy ( P homogeneity=0.8) or the presence of hypertension ( P homogeneity=0.4). Conclusions— For most patients with atrial fibrillation, routine blood pressure–lowering is likely to provide protection against major vascular events additional to that conferred by anticoagulation.
Cognitive function and risks of cardiovascular disease and hypoglycaemia in patients with type 2 diabetes: the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controll
Publisher: Springer Science and Business Media LLC
Date: 18-08-2009
DOI: 10.1007/S00125-009-1484-7
Abstract: The relationship between cognitive function, cardiovascular disease and premature death is not well established in patients with type 2 diabetes. We assessed the effects of cognitive function in 11,140 patients with type 2 diabetes who participated in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial. Furthermore, we tested whether level of cognitive function altered the beneficial effects of the BP-lowering and glycaemic-control regimens in the trial. Cognitive function was assessed using the Mini Mental State Examination at baseline, and defined by scores 28-30 ('normal', n = 8,689), 24-27 ('mild dysfunction', n = 2,231) and <24 ('severe dysfunction', n = 212). Risks of major cardiovascular events, death and hypoglycaemia and interactions with treatment were assessed using Cox proportional hazards analysis. Relative to normal function, both mild and severe cognitive dysfunction significantly increased the multiple-adjusted risks of major cardiovascular events (HR 1.27, 95% CI 1.11-1.46 and 1.42, 95% CI 1.01-1.99 both p < 0.05), cardiovascular death (1.41, 95% CI 1.16-1.71 and 1.56, 95% CI 0.99-2.46 both p <or= 0.05) and all-cause death (1.33, 95% CI 1.16-1.54 and 1.50, 95% CI 1.06-2.12 both p < 0.03). Severe, but not mild, cognitive dysfunction increased the risk of severe hypoglycaemia (HR 2.10, 95% CI 1.14-3.87 p = 0.018). There was no evidence of heterogeneity of treatment effects on cardiovascular outcomes in subgroups defined by cognitive function at baseline. Cognitive dysfunction is an independent predictor of clinical outcomes in patients with type 2 diabetes, but does not modify the effects of BP lowering or glucose control on the risks of major cardiovascular events. ClinicalTrials.gov NCT00145925.
Sex differences in treatment, radiological features and outcome after intracerebral haemorrhage: Pooled analysis of Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials 1 and 2
Publisher: SAGE Publications
Date: 20-09-2020
Abstract: Reports vary on how sex influences the management and outcome from acute intracerebral haemorrhage. We aimed to quantify sex disparities in clinical characteristics, management, including response to blood pressure lowering treatment, and outcomes in patients with acute intracerebral haemorrhage, through interrogation of two large clinical trial databases. Post-hoc pooled analysis of the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials 1 and 2, where patients with a hypertensive response (systolic, 150–220 mmHg) after spontaneous intracerebral haemorrhage ( h) were randomised to intensive (target mmHg h) or guideline-recommended ( mmHg) blood pressure lowering treatment. The interaction of sex on early haematoma growth (24 h), death or major disability (modified Rankin scale scores 3–6 at 90 days), and effect of randomised treatment were determined in multivariable logistic regression models adjusted for baseline confounding variables. In 3233 participants, 1191 (37%) were women who were significantly older, had higher baseline National Institutes of Health Stroke Scale scores and smaller haematoma volumes compared to men. Men had higher three-month mortality (odds ratio 1.48, 95% confidence interval 1.10–2.00) however, there was no difference between women and men in the combined endpoint of death or major disability. There were no significant sex differences on mean haematoma growth or effect of randomised blood pressure lowering treatment. Men included in the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials had more comorbidities, larger baseline haematoma volumes and higher mortality after adjustment for age, as compared with women. Men included in the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials had a greater odds of dying after intracerebral haemorrhage than women, which could not be readily explained by differing casemix or patterns of blood pressure management. The Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials studies are registered with ClinicalTrials.gov (NCT00226096 and NCT00716079).
Trends in Stroke Incidence in Auckland, New Zealand, During 1981 to 2003
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2005
DOI: 10.1161/01.STR.0000181079.42690.BF
Abstract: Background and Purpose— Long-term trends in stroke incidence in different populations have not been well characterized, largely as a result of the complexities associated with population-based stroke surveillance. Methods— We assessed temporal trends in stroke incidence using standard diagnostic criteria and community-wide surveillance procedures in the population (≈1 million) of Auckland, New Zealand, over 12-month calendar periods in 1981–1982, 1991–1992, and 2002–2003. Age-adjusted first-ever (incident) and total (attack) rates, and temporal trends, were reported with 95% confidence intervals (CIs). Rates were analyzed by sex and major age groups. Results— From 1981 to 1982, stroke rates were stable in 1991–1992 and then declined in 2002–2003, to produce overall modest declines in standardized incidence (11% 95% CI, 1 to 19%) and attack rates (9% 95% CI, 0 to 16%) between the first and last study periods. Some favorable downward trends in vascular risk factors such as cigarette smoking were counterbalanced by increasing age and body mass index, and frequency of diabetes, in patients with stroke. Conclusions— There has been a modest decline in stroke incidence in Auckland over the last 2 decades, mainly during 1991 to 2003, in association with ergent trends in major risk factors.
Review of Long-Term Blood Pressure Control After Intracerebral Hemorrhage: Challenges and Opportunities.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2022
DOI: 10.1161/STROKEAHA.121.036885
Abstract: Blood pressure (BP) is the most important modifiable risk factor for intracerebral hemorrhage (ICH). Elevated BP is associated with an increased risk of ICH, worse outcome after ICH, and in survivors, higher risks of recurrent ICH, ischemic stroke, myocardial infarction, and cognitive impairment/dementia. As intensive BP control probably improves the chances of recovery from acute ICH, the early use of intravenous or oral medications to achieve a systolic BP goal of mm Hg within the first few hours of presentation is reasonable for being applied in most patients. In the long-term, oral antihypertensive drugs should be titrated as soon as possible to achieve a goal BP /80 mm Hg and again in all ICH patients regardless of age, location, or presumed mechanism of ICH. The degree of sustained BP reduction, rather than the choice of BP-lowering agent(s), is the most important factor for optimizing risk reduction, with varying combinations of thiazide-type diuretics, long-acting calcium channel blockers, ACE (angiotensin-converting enzyme) inhibitors or angiotensin receptor blockers, being the mainstay of therapy. As most patients will require multiple BP-lowering agents, and physician inertia and poor adherence are major barriers to effective BP control, single-pill combination therapy should be considered as the choice of management where available. Increased population and clinician awareness, and innovations to solving patient, provider, and social factors, have much to offer for improving BP control after ICH and more broadly across high-risk groups. It is critical that all physicians, especially those managing ICH patients, emphasize the importance of BP control in their practice.
Antithrombotics prescription and adherence among stroke survivors: A systematic review and meta‐analysis
Publisher: Wiley
Date: 06-09-2022
DOI: 10.1002/BRB3.2752
Abstract: We aimed to investigate the prescription of antithrombotic drugs (including anticoagulants and antiplatelets) and medication adherence after stroke. We performed a systematic literature search across MEDLINE and Embase, from January 1, 2015, to February 17, 2022, to identify studies reporting antithrombotic medications (anticoagulants and antiplatelets) post stroke. Two people independently identified reports to include, extracted data, and assessed the quality of included studies according to the Newcastle–Ottawa scale. Where possible, data were pooled using random‐effects meta‐analysis. We included 453,625 stroke patients from 46 studies. The pooled proportion of prescribed antiplatelets and anticoagulants among patients with atrial fibrillation (AF) was 62% (95% CI: 57%–68%), and 68% (95% CI: 58%–79%), respectively. The pooled proportion of patients who were treated according to the recommendation of guidelines of antithrombotic medications from four studies was 67% (95% CI: 41%–93%). It was reported that 11% (95% CI: 2%–19%) of patients did not receive antithrombotic medications. Good adherence to antiplatelet, anticoagulant, and antithrombotic medications was 78% (95% CI: 67%–89%), 71% (95% CI: 57%–84%), and 73% (95% CI: 59%–86%), respectively. In conclusion, we found that less than 70% of patients were prescribed and treated according to the recommended guidelines of antithrombotic medications, and good adherence to antithrombotic medications is only 73%. Prescription rate and good adherence to antithrombotic medications still need to be improved among stroke survivors.
Life-sustaining treatment and locked-in syndrome
Publisher: Elsevier BV
Date: 10-1993
Ethnicity and Functional Outcome After Stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2011
DOI: 10.1161/STROKEAHA.110.605139
Abstract: There is limited information on the influence of ethnicity on functional outcome after stroke. We examined functional outcomes among European New Zealanders, Māori, Pacific, and Asian people 6 months after stroke in a population-based context. This was a prospective incidence and 6-month outcomes study of all new stroke patients (excluding subarachnoid hemorrhage) that occurred over 1 year in a defined geographical area in Auckland, New Zealand, during 2002 to 2003. Ethnicity was self-defined. Outcome measures included the Frenchay Activities Index, 36-item Short Form questionnaire, independence, death, composite of death and dependence, and living situation. Functional measures were available in 1127 patients 6 months after stroke. Frenchay Activities Index scores were associated with ethnicity on both univariable and multivariable analysis, with Asian and Pacific people having worse scores. Physical Component Summary score of the 36-item Short Form was associated with ethnicity on univariable (scores for Pacific, Māori, and Asian people were higher than those for Europeans) but not multivariable analysis. Asian people were less likely to be dead compared to Europeans, and Pacific people were more likely to be dependent on others for help than Europeans. Pacific people were more likely to be dead or dependent than Europeans. Asian and Pacific people were more likely to be living at home than Europeans. Ethnicity was associated independently with functional outcomes. The association was attenuated when adjusted for stroke severity and other covariates. The direction of the relationship was not consistent between measures for in idual ethnic groups.
Differing Risk Factor Profiles of Ischemic Stroke Subtypes
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2010
DOI: 10.1161/STROKEAHA.109.558809
Abstract: Background and Purpose— Differences in risk factor profiles between lacunar and other ischemic stroke subtypes may provide evidence for a distinct lacunar arteriopathy, but existing studies have limitations. We overcame these by pooling in idual data on 2875 patients with first-ever ischemic stroke from 5 collaborating prospective stroke registers that used similar, unbiased methods to define risk factors and classify stroke subtypes. Methods— We compared risk factors between lacunar and nonlacunar ischemic strokes, altering the comparison groups in sensitivity analyses, and incorporated these data into a meta-analysis of published studies. Results— Unadjusted and adjusted analyses gave similar results. We found a lower prevalence of cardioembolic source (adjusted odds ratio, 0.33 95% CI, 0.24 to 0.46), ipsilateral carotid stenosis (odds ratio, 0.21 95% CI, 0.14 to 0.30), and ischemic heart disease (odds ratio, 0.75 95% CI, 0.58 to 0.97) in lacunar compared with nonlacunar patients but no difference for hypertension, diabetes, or any other risk factor studied. Results were robust to sensitivity analyses and largely confirmed in our meta-analysis. Conclusions— Hypertension and diabetes appear equally common in lacunar and nonlacunar ischemic stroke, but lacunar stroke is less likely to be caused by embolism from the heart or proximal arteries, and the lower prevalence of ischemic heart disease in lacunar stroke provides additional support for a nonatherosclerotic arteriopathy causing many lacunar ischemic strokes. Our findings have implications for how clinicians classify ischemic stroke subtypes and highlight the need for additional research into the specific causes of and treatments for lacunar stroke.
Disparities in Stroke Incidence Over Time by Sex and Age in Latin America and the Caribbean Region 1997 to 2021: A Systematic Review and Meta‐Analysis
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-09-2023
Abstract: High‐income country studies show unfavorable trends in stroke incidence (SI) in younger populations. We aimed to estimate temporal change in SI disaggregated by age and sex in Latin America and the Caribbean region. A search strategy was used in MEDLINE, WOS, and LILACS databases from 1997 to 2021, including prospective population‐based observational studies with first‐ever stroke incidence in Latin America. Reports without data broken down by age and sex were excluded. Risk of bias was assessed with The Joanna Briggs Institute's guide. The main outcomes were incidence rate ratio and relative temporal trend ratio of SI, comparing time periods before 2010 with after 2010. Pooled relative temporal trend ratios considering only studies with 2 periods in the same population were calculated by random‐effects meta‐analysis. Meta‐regression analysis was used to evaluate incidence rate determinants. From 9242 records identified, 6 studies were selected including 4483 first‐ever stroke in 4 101 084 in iduals. Crude incidence rate ratio in younger subjects ( years) comparing before 2010:after 2010 periods showed an increase in SI in the past decade (incidence rate ratio, 1.37 [95% CI, 1.23–1.50]), in contrast to a decrease in older people during the same period (incidence rate ratio, 0.83 [95% CI, 0.76–0.89]). Overall relative temporal trend ratio ( :≥55 years) was 1.65 (95 CI%, 1.50–1.80), with higher increase in young women (pooled relative temporal trend ratio, 3.08 [95% CI, 1.18–4.97] P for heterogeneity .001). An unfavorable change in SI in young people, especially in women, was detected in population‐based studies in the past decade in Latin America and the Caribbean. Further investigation of the explanatory variables is required to ameliorate stroke prevention and inform local decision‐makers. URL: www.crd.york.ac.uk rospero/ Identifier: CRD42022332563.
Prolonged hypotension following elective stenting of an internal carotid artery stenosis.
Publisher: BMJ
Date: 15-01-2014
DOI: 10.1136/NEURINTSURG-2013-011016.REP
Abstract: We report a case of a 72-year-old man who had undergone elective stenting of an asymptomatic high grade stenosis of the proximal left internal carotid artery. The indication was progression of the stenosis over a 3 year period despite receiving maximal medical therapy, and patient preference for stenting over endarterectomy. He became profoundly hypotensive in the immediate post-stent period and required immediate and prolonged vasopressor support over the next week. The etiological hypothesis is baroreceptor hyperactivity related to procedure induced unilateral stretching of the carotid body.
Related Organisations
National Health And Medical Research Council
Location: No location found
Related Funding Activities
No related grants have been discovered for Craig Anderson.