| 1. |
- Katsanos, Aristeidis H, et al.
(författare)
-
Blood Pressure After Endovascular Thrombectomy and Outcomes in Patients With Acute Ischemic Stroke: An Individual Patient Data Meta-analysis.
- 2022
-
Ingår i: Neurology. - 1526-632X. ; 98:3
-
Tidskriftsartikel (refereegranskat)abstract
- To explore the association between blood pressure (BP) levels after endovascular thrombectomy (EVT) and the clinical outcomes of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO).A study was eligible if it enrolled AIS patients older than 18 years, with an LVO treated with either successful or unsuccessful EVT, and provided either individual or mean 24-hour systolic BP values after the end of the EVT procedure. Individual patient data from all studies were analyzed using a generalized linear mixed-effects model.A total of 5874 patients (mean age: 69±14 years, 50% women, median NIHSS on admission: 16) from 7 published studies were included. Increasing mean systolic BP levels per 10 mm Hg during the first 24 hours after the end of the EVT were associated with a lower odds of functional improvement (unadjusted common OR=0.82, 95%CI:0.80-0.85; adjusted common OR=0.88, 95%CI:0.84-0.93) and modified Ranking Scale score≤2 (unadjusted OR=0.82, 95%CI:0.79-0.85; adjusted OR=0.87, 95%CI:0.82-0.93), and a higher odds of all-cause mortality (unadjusted OR=1.18, 95%CI:1.13-1.24; adjusted OR=1.15, 95%CI:1.06-1.23) at 3 months. Higher 24-hour mean systolic BP levels were also associated with an increased likelihood of early neurological deterioration (unadjusted OR=1.14, 95%CI:1.07-1.21; adjusted OR=1.14, 95%CI:1.03-1.24) and a higher odds of symptomatic intracranial hemorrhage (unadjusted OR=1.20, 95%CI:1.09-1.29; adjusted OR=1.20, 95%CI:1.03-1.38) after EVT.Increased mean systolic BP levels in the first 24 hours after EVT are independently associated with a higher odds of symptomatic intracranial hemorrhage, early neurological deterioration, three-month mortality, and worse three-month functional outcomes.
|
|
| 2. |
- Goyal, Nitin, et al.
(författare)
-
Medical Management vs Mechanical Thrombectomy for Mild Strokes: An International Multicenter Study and Systematic Review and Meta-analysis
- 2020
-
Ingår i: JAMA Neurology. - : American Medical Association (AMA). - 2168-6149. ; 77:1, s. 16-24
-
Tidskriftsartikel (refereegranskat)abstract
- © 2019 American Medical Association. All rights reserved. Importance: The benefit of mechanical thrombectomy (MT) in patients with stroke presenting with mild deficits (National Institutes of Health Stroke Scale [NIHSS] score <6) owing to emergency large-vessel occlusion (ELVO) remains uncertain. Objective: To assess the outcomes of patients with mild-deficits ELVO (mELVO) treated with MT vs best medical management (bMM). Data Sources: We retrospectively pooled patients with mELVO during a 5-year period from 16 centers. A meta-analysis of studies reporting efficacy and safety outcomes with MT or bMM among patients with mELVO was also conducted. Data were analyzed between 2013 and 2017. Study Selection: We identified studies that enrolled patients with stroke (within 24 hours of symptom onset) with mELVO treated with MT or bMM. Main Outcomes and Measures: Efficacy outcomes included 3-month favorable functional outcome and 3-month functional independence that were defined as modified Rankin Scale scores of 0 to 1 and 0 to 2, respectively. Safety outcomes included 3-month mortality and symptomatic and asymptomatic intracranial hemorrhage (ICH). Results: We evaluated a total of 251 patients with mELVO who were treated with MT (n = 138; 65 women; mean age, 65.2 years; median NIHSS score, 4; interquartile range [IQR], 3-5) or bMM (n = 113; 51 women; mean age, 64.8; median NIHSS score, 3; interquartile range [IQR], 2-4). The rate of asymptomatic ICH was lower in bMM (4.6% vs 17.5%; P =.002), while the rate of 3-month FI (after imputation of missing follow-up evaluations) was lower in MT (77.4% vs 88.5%; P =.02). The 2 groups did not differ in any other efficacy or safety outcomes. In multivariable analyses, MT was associated with higher odds of asymptomatic ICH (odds ratio [OR], 11.07; 95% CI, 1.31-93.53; P =.03). In the meta-analysis of 4 studies (843 patients), MT was associated with higher odds of symptomatic ICH in unadjusted analyses (OR, 5.52; 95% CI, 1.91-15.49; P =.002; I2 = 0%). This association did not retain its significance in adjusted analyses including 2 studies (OR, 2.06; 95% CI, 0.49-8.63; P =.32; I2 = 0%). The meta-analysis did not document any other independent associations between treatment groups and safety or efficacy outcomes. Conclusions and Relevance: Our multicenter study coupled with the meta-analysis suggests similar outcomes of MT and bMM in patients with stroke with mELVO, but no conclusions about treatment effect can be made. The clinical equipoise can further be resolved by a randomized clinical trial.
|
|
| 3. |
- Psychogios, Marios, et al.
(författare)
-
European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease
- 2022
-
Ingår i: European Stroke Journal. - : SAGE Publications. - 2396-9881 .- 2396-9873.
-
Tidskriftsartikel (refereegranskat)abstract
- The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-basedrecommendations on the management of patients with intracranial atherosclerotic disease (ICAD). The guidelines wereprepared following the Standard Operational Procedure of the European Stroke Organisation guidelines and accordingto GRADE methodology. ICAD represents a major cause of ischemic stroke worldwide, and patients affected by thiscondition are exposed to a high risk for future strokes and other major cardiovascular events, despite best medicaltherapy available. We identified 11 relevant clinical problems affecting ICAD patients and formulated the correspondingPopulation Intervention Comparator Outcomes (PICO) questions. The first two questions refer to the asymptomaticstage of the disease, which is being increasingly detected thanks to the routine use of noninvasive vascular imaging. Wewere not able to provide evidence-based recommendations regarding the optimal detection strategy and management ofasymptomatic ICAD, and further research in the field is encouraged as subclinical ICAD may represent a big opportunityto improve primary stroke prevention. The second block of PICOs (3–5) is dedicated to the management of acutelarge vessel occlusion (LVO) ischemic stroke caused by ICAD, a clinical presentation of this disease that is becomingincreasingly relevant and problematic, since it is associated with more refractory endovascular reperfusion procedures.An operational definition of probable ICAD-related LVO is proposed in the guideline. Despite the challenging context,no dedicated randomized clinical trials (RCTs) were identified, and therefore the guideline can only provide withsuggestions derived from observational studies and our expert consensus, such as the escalated use of glycoproteinIIb-IIIa inhibitors and angioplasty/stenting in cases of refractory thrombectomies due to underlying ICAD. The last blockof PICOs is devoted to the secondary prevention of patients with symptomatic ICAD. Moderate-level evidence wasfound to recommend against the use of oral anticoagulation as preferred antithrombotic drug, in favor of antiplatelets.Low-level evidence based our recommendation in favor of double antiplatelet as the antithrombotic treatment of choicein symptomatic ICAD patients, which we suggest to maintain during 90days as per our expert consensus. Endovasculartherapy with intracranial angioplasty and or stenting is not recommended as a treatment of first choice in high-gradesymptomatic ICAD (moderate-level evidence). Regarding neurosurgical interventions, the available evidence does notsupport their use as front line therapies in patients with high-grade ICAD. There is not enough evidence as to provideany specific recommendation regarding the use of remote ischemic conditioning in ICAD patients, and further RCTsare needed to shed light on the utility of this promising therapy. Finally, we dedicate the last PICO to the importanceof aggressive vascular risk factor management in ICAD, although the evidence derived from RCTs specifically addressingthis question is still scarce
|
|
| 4. |
- Wardlaw, Joanna M., et al.
(författare)
-
European stroke organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke
-
Ingår i: European Stroke Journal. - 2396-9873.
-
Tidskriftsartikel (refereegranskat)abstract
- A quarter of ischaemic strokes are lacunar subtype, typically neurologically mild, usually resulting from intrinsic cerebral small vessel pathology, with risk factor profiles and outcome rates differing from other stroke subtypes. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations to assist with clinical decisions about management of lacunar ischaemic stroke to prevent adverse clinical outcomes. The guideline was developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We addressed acute treatment (including progressive lacunar stroke) and secondary prevention in lacunar ischaemic stroke, and prioritised the interventions of thrombolysis, antiplatelet drugs, blood pressure lowering, lipid lowering, lifestyle, and other interventions and their potential effects on the clinical outcomes recurrent stroke, dependency, major adverse cardiovascular events, death, cognitive decline, mobility, gait, or mood disorders. We systematically reviewed the literature, assessed the evidence and where feasible formulated evidence-based recommendations, and expert concensus statements. We found little direct evidence, mostly of low quality. We recommend that patients with suspected acute lacunar ischaemic stroke receive intravenous alteplase, antiplatelet drugs and avoid blood pressure lowering according to current acute ischaemic stroke guidelines. For secondary prevention, we recommend single antiplatelet treatment long-term, blood pressure control, and lipid lowering according to current guidelines. We recommend smoking cessation, regular exercise, other healthy lifestyle modifications, and avoid obesity for general health benefits. We cannot make any recommendation concerning progressive stroke or other drugs. Large randomised controlled trials with clinically important endpoints, including cognitive endpoints, are a priority for lacunar ischaemic stroke.
|
|
