| 1. |
- Ahmed, Niaz, et al.
(author)
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Association of Admission Blood Glucose and Outcome in Patients Treated With Intravenous Thrombolysis
- 2010
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In: Archives of Neurology. - 0003-9942 .- 1538-3687. ; 67:9, s. 1123-1130
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Journal article (peer-reviewed)abstract
- Objective: To determine the association between admission blood glucose and outcome in ischemic stroke patients treated with thrombolysis. Design: A prospective, open, multinational, observational study. Setting: An ongoing Internet-based, academic-driven, interactive thrombolysis register. Patients: Between 2002 and 2007, 16 049 patients were recorded in the SITS-ISTR. Main Outcome Measure: Blood glucose was recorded at admission. Blood glucose was divided into the following categories: less than 80,80-120 (reference range), 121-140, 141-160, 161-180, 181-200, and greater than 200 mg/dL. Outcomes were mortality and independence (modified Rankin Scale score of 0-2) at 3 months and symptomatic intracerebral hemorrhage (SICH) (National Institutes of Health Stroke Scale deterioration >= points within 24 hours and type 2 parenchymal hemorrhage). Results: In multivariable analysis, blood glucose as a continuous variable was independently associated with a higher mortality (P < .001), lower independence (P < .001), and an increased risk of SICH (P = .005). Blood glucose greater than 120 mg/dL as a categorical variable was associated with a significantly higher odds for mortality (odds ratio [OR], 1.24; 95% confidence interval [Cl], 1.07-1.44; P = .004) and a lower odds for independence (OR, 0.58; 95% CI, 0.48-0.70; P < .001), and blood glucose from 181 to 200 mg/dL was associated with an increased risk of SICH (OR, 2.86; 95% CI, 1.69-4.83; P < .001) compared with the reference level. The trends of associations between blood glucose and outcomes were similar in patients with diabetes (17%) or without such history, except for mortality (P = .23) and SICH (P = .06) in which the association was not statistically significant in patients with diabetes. Conclusions: Admission hyperglycemia was an independent predictor for poor outcome after stroke/thrombolysis, though SICH rates did not increase significantly until reaching 180 mg/dL. These results suggest that tight control of blood glucose may be indicated in the hyperacute phase following thrombolysis. Randomized trial data are needed.
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| 2. |
- Ahmed, Niaz
(author)
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Blood pressure in acute ischaemic stroke : blood pressure and stress in the acute phase of stroke and influence of initial blood pressure on stroke-outcome
- 2003
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Doctoral thesis (other academic/artistic)abstract
- Background and objectives: Most patients (70-80%) with acute ischaemic or haemorrhagic stroke exhibit a high systemic blood pressure (BP) on admission to hospital even in the absence of a history of hypertension (=50%). In matched-control patients admitted to hospital for other acute diseases the proportion of high BP is only 36%. For most patients this high initial BP falls spontaneously without anti-hypertensive treatments over the next few days. The cause and exact mechanism of high BP during the acute phase of stroke is still unknown and mental stress is often suggested as a main contributing factor. There is conflicting evidence regarding the relationship between high initial BP, lowering of high initial BP and outcome after acute stroke. The objectives of this thesis were (I) to examine the relationship between nimodipine (a calcium channel blocker) induced reduction of BP and outcome, 01) to evaluate the relationship between high initial BP and outcome, (III) to investigate whether heterogeneity exists between stroke subtypes in the response to BP lowering treatment and (IV) to investigate the relationship between BP and stress as evaluated by salivary cortisol and psychological tests in patients with acute ischaemic stroke. Subjects & methods: To fulfil objectives I-III, a dataset from a previously performed clinical trial (Intravenous Nimodipine West European Stroke Trial, INWEST) was analysed and to fulfil objective IV, a prospective study was performed. In both studies, patients with a clinical diagnosis of stroke (within 24-hours of symptoms onset) were studied after exclusion of haemorrhage by computer tomography scans. In INWEST, patients were consecutively all ocated to placebo (n=100), 1mg/hour (low-dose) intravenous (i.v.) nimodipine (n=101) or 2mg/hour (high-dose) i.v. nimodipine (n=94) for 5 days followed by oral treatment for 16 days in a double blind manner. Thirty patients were excluded from the analysis (n=8 in placebo, 8 and 14 in low-dose and high-dose group respectively). In the prospective study, 58 patients were recruited. BP and pulse rate was recorded by non-invasive automatic monitoring hourly for 24-hours. Stress was evaluated by testing the level of salivary cortisol (4-samples within 24hours after inclusion) and psychological tests at the time of inclusion. Results & conclusion: Nimodipine treatment (i.v.) resulted in a statistically significant reduction of systolic BP (SBP) and diastolic BP (DBP) compared to placebo. In the high-dose nimodipine group, DBP reduction during the first 48-hours but not SBP was associated with neurological worsening at 2 1 -days. A DBP reduction of > 20% by high-dose nimodipine was associated with poor outcome of combined death or dependency (Barthel Index<60) and death alone compared to placebo. For DBP reduction of <20% by high-dose nimodipine, and any DBP reduction by low-dose nimodipine the results were not conclusive (paper I). For all treatment groups combined (n=265) and also for placebo (n=92), patients with high initial BP (>160/90 mm Hg) had a poor functional outcome (combined death or dependency) at 21-days compared to patients with normal initial BP (120-160/60-90 min Hg). Patients with low initial BP (<120/60) also had a poor functional outcome compared to patients with normal initial BP (paper II). While classifying stroke according to the OCSP (Oxfordshire Community Stroke Project), 106 patients were identified as having Total Anterior Circulation Infarcts (TACI) with hemiparesis, dysphasia and homonymous hemianopia and 62 as non-TACI after exclusion of any of the above symptoms. Nimodipine treatment and BP change had no significant effect on outcome for TACT patients. For non-TACI patients, DBP reduction was associated with poor neurological outcome and high-dose minodipine worsened both neurological and functional outcome (paper III). A biological marker of stress, salivary cortisol, was positively related to 24-hours SBP and night-time BP, suggesting that stress is a contributing factor for high BP in acute stroke. Psychological stress tests were difficult to perform in acute stroke and those performed did not correlate with BP or cortisol level (paper IV).
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| 3. |
- Ahmed, Niaz, et al.
(author)
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Consensus statements and recommendations from the ESO-Karolinska Stroke Update Conference, Stockholm 11-13 November 2018.
- 2019
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In: European Stroke Journal. - : SAGE Publications. - 2396-9873 .- 2396-9881. ; 4:4, s. 307-317
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Journal article (peer-reviewed)abstract
- The purpose of the European Stroke Organisation-Karolinska Stroke Update Conference is to provide updates on recent stroke therapy research and to give an opportunity for the participants to discuss how these results may be implemented into clinical routine. The meeting started 22 years ago as Karolinska Stroke Update, but since 2014 it is a joint conference with European Stroke Organisation. Importantly, it provides a platform for discussion on the European Stroke Organisation guidelines process and on recommendations to the European Stroke Organisation guidelines committee on specific topics. By this, it adds a direct influence from stroke professionals otherwise not involved in committees and work groups on the guideline procedure. The discussions at the conference may also inspire new guidelines when motivated. The topics raised at the meeting are selected by the scientific programme committee mainly based on recent important scientific publications. This year's European Stroke Organisation-Karolinska Stroke Update Meeting was held in Stockholm on 11-13 November 2018. There were 11 scientific sessions discussed in the meeting including two short sessions. Each session except the short sessions produced a consensus statement (Full version with background, issues, conclusions and references are published as web-material and at www.eso-karolinska.org and http://eso-stroke.org) and recommendations which were prepared by a writing committee consisting of session chair(s), scientific secretary and speakers. These statements were presented to the 250 participants of the meeting. In the open meeting, general participants commented on the consensus statement and recommendations and the final document were adjusted based on the discussion from the general participants Recommendations (grade of evidence) were graded according to the 1998 Karolinska Stroke Update meeting with regard to the strength of evidence. Grade A Evidence: Strong support from randomised controlled trials and statistical reviews (at least one randomised controlled trial plus one statistical review). Grade B Evidence: Support from randomised controlled trials and statistical reviews (one randomised controlled trial or one statistical review). Grade C Evidence: No reasonable support from randomised controlled trials, recommendations based on small randomised and/or non-randomised controlled trials evidence.
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| 4. |
- Ahmed, Niaz, et al.
(author)
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Effect of intravenous nimodipine on blood pressure and outcome after acute stroke
- 2000
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In: Stroke. - 0039-2499 .- 1524-4628. ; 31:6, s. 1250-1255
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Journal article (peer-reviewed)abstract
- Background and Purpose-The Intravenous Nimodipine West European Stroke Trial (INWEST) found a correlation between nimodipine-induced reduction in blood pressure (BP) and an unfavorable outcome in acute stroke. We sought to confirm this correlation with and without adjustment for prognostic variables and to investigate outcome in subgroups with increasing levels of BP reduction. Methods-Patients with a clinical diagnosis of ischemic stroke (within 24 hours) were consecutively allocated to receive placebo (n=100), 1 mg/h (low-dose) nimodipine (n=101), or 2 mg/h (high-dose) nimodipine (n=94). The correlation between average BP change during the first 2 days and the outcome at day 21 was analysed. Results-Two hundred sixty-five patients were included in this analysis (n=92, 93, and 80 for placebo, low dose, and high dose. respectively). Nimodipine treatment resulted in a statistically significant reduction in systolic BP (SBP) and diastolic BP (DBP) from baseline compared with placebo during the first few days. In multivariate analysis, a significant correlation between DBP reduction and worsening of the neurological score was round for the high-close group (beta=0.49, P=0.048). Patients with a DBP reduction of greater than or equal to 20% in the high-dose group had a significantly increased adjusted OR for the compound outcome variable death or dependency (Barthel Index <60) (n/N=25/26, OR 10.16, 95% CI 1.02 to 101.74) and death alone (n/N=9/26, OR 4.3361 95% CI 1.131 16.619) compared with all placebo patients (n/N=62/92 and 14/92. respectively). There was no correlation between SEP change and outcome. Conclusions-DBP, but not SEP, reduction was associated with neurological worsening after the intravenous administration of high-dose nimodipine after acute stroke. For low-dose nimodipine, the results were not conclusive. These results do not confirm or exclude a neuroprotective property of nimodipine.
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| 5. |
- Ahmed, Niaz, et al.
(author)
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Recommendations from the ESO-Karolinska Stroke Update Conference, Stockholm 13–15 November 2016
- 2017
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In: European Stroke Journal. - : SAGE Publications. - 2396-9873 .- 2396-9881. ; 2:2, s. 95-102
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Journal article (peer-reviewed)abstract
- About the meeting: The purpose of the European Stroke Organisation (ESO)-Karolinska Stroke Update Conference is to provide updates on recent stroke therapy research and to give an opportunity for the participants to discuss how these results may be implemented into clinical routine. Several scientific sessions discussed in the meeting and each session produced consensus statements. The meeting started 20 years ago as Karolinska Stroke Update, but since 2014, it is a joint conference with ESO. Importantly, it provides a platform for discussion on the ESO guidelines process and on recommendations to the ESO guidelines committee on specific topics. By this, it adds a direct influence from stroke professionals otherwise not involved in committees and work groups on the guidelines procedure. The discussions at the conference may also inspire new guidelines when motivated. The topics raised at the meeting are selected by the scientific programme committee mainly based on recent important scientific publications. The ESO-Karolinska Stroke Update consensus statement and recommendations will be published every 2 years and it will work as implementation of ESO-guidelinesBackground: This year’s ESO-Karolinska Stroke Update Meeting was held in Stockholm on 13–15 November 2016. There were 10 scientific sessions discussed in the meeting and each session produced a consensus statement (Full version with background, issues, conclusions and references are published as web-material and at http://www.eso-karolinska.org/2016 and http://eso-stroke.org) and recommendations which were prepared by a writing committee consisting of session chair(s), secretary and speakers and presented to the 312 participants of the meeting. In the open meeting, general participants commented on the consensus statement and recommendations and the final document were adjusted based on the discussion from the general participants.Recommendations (grade of evidence) were graded according to the 1998 Karolinska Stroke Update meeting with regard to the strength of evidence. Grade A Evidence: Strong support from randomised controlled trials and statistical reviews (at least one randomised controlled trial plus one statistical review). Grade B Evidence: Support from randomised controlled trials and statistical reviews (one randomised controlled trial or one statistical review). Grade C Evidence: No reasonable support from randomised controlled trials, recommendations based on small randomised and/or non-randomised controlled trials evidence.
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| 6. |
- Ahmed, Niaz, et al.
(author)
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The SITS Open Study: A Prospective, Open Label Blinded Evaluation Study of Thrombectomy in Clinical Practice.
- 2021
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In: Stroke. - 1524-4628. ; 52:3, s. 792-801
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Journal article (peer-reviewed)abstract
- We designed SITS (Safe Implementation of Treatment in Stroke) Open to determine benefit and safety of thrombectomy in clinical practice for large artery occlusion stroke, using selected stent retrievers plus standard care versus standard care alone.SITS Open was a prospective, open, blinded evaluation, international, multicenter, controlled, nonrandomized registry study. Centers lacking access to thrombectomy contributed controls. Primary end point was categorical shift in modified Rankin Scale score at 3 months in the per protocol (PP) population. Principal secondary outcomes were symptomatic intracranial hemorrhage, functional independency (modified Rankin Scale score 0-2) and death at 3 months. Patients independently evaluated by video-recorded modified Rankin Scale interviews blinded to treatment or center identity by central core laboratory were regarded as PP population. Propensity score matching with covariate adjusted analysis was performed.During 2014 to 2017, 293 patients (257 thrombectomy, 36 control) from 26 centers in 10 countries fulfilled intention-to-treat and 200 (170 thrombectomy, 30 control) PP criteria; enrollment of controls was limited by rapid uptake of thrombectomy. In PP analysis, median age was 71 versus 71 years, and baseline National Institutes of Health Stroke Scale 17 versus 17 in the thrombectomy and control arms, respectively. The propensity score matching analysis for PP showed a significant shift for modified Rankin Scale at 3 months favoring the thrombectomy group (odds ratio, 3.8 [95% CI, 1.61-8.95]; P=0.002). Regarding safety, there were 4 cases of symptomatic intracranial hemorrhage in the thrombectomy group (2.4%) and none in the control group.In clinical practice, thrombectomy for patients with large artery occlusion stroke is superior to standard of care in our study. Registration: URL: https://www.clinicaltrials.gov. Unique Identifier: NCT02326428.
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| 7. |
- Ahmed, Toqeer, et al.
(author)
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Water-related impacts of climate change on agriculture and subsequently on public health : A review for generalists with particular reference to Pakistan
- 2016
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In: International Journal of Environmental Research and Public Health. - : MDPI AG. - 1661-7827 .- 1660-4601. ; 13:11
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Research review (peer-reviewed)abstract
- Water-related impacts due to change in climatic conditions ranging from water scarcity to intense floods and storms are increasing in developing countries like Pakistan. Water quality and waterborne diseases like hepatitis, cholera, typhoid, malaria and dengue fever are increasing due to chaotic urbanization, industrialization, poor hygienic conditions, and inappropriate water management. The morbidity rate is high due to lack of health care facilities, especially in developing countries. Organizations linked to the Government of Pakistan (e.g., Ministry of Environment, Ministry of Climate Change, Planning and Development, Ministry of Forest, Irrigation and Public Health, Pakistan Meteorological Department, National Disaster Management, Pakistan Agricultural Research Centre, Pakistan Council for Research in Water Resources, and Global Change Impact Study Centre), United Nation organizations, provincial government departments, non-governmental organizations (e.g., Global Facility and Disaster Reduction), research centers linked to universities, and international organizations (International Institute for Sustainable Development, Food and Agriculture, Global Climate Fund and World Bank) are trying to reduce the water-related impacts of climate change, but due to lack of public awareness and health care infrastructure, the death rate is steadily increasing. This paper critically reviews the scientific studies and reports both at national and at international level benefiting generalists concerned with environmental and public health challenges. The article underlines the urgent need for water conservation, risk management, and the development of mitigation measures to cope with the water-related impacts of climate change on agriculture and subsequently on public health. Novel solutions and bioremediation methods have been presented to control environmental pollution and to promote awareness among the scientific community. The focus is on diverse strategies to handle the forthcoming challenges associated with water resources management.
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| 8. |
- Ain, Noor U., et al.
(author)
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Biallelic TMEM251 variants in patients with severe skeletal dysplasia and extreme short stature
- 2020
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In: Human Mutation. - : John Wiley & Sons. - 1059-7794 .- 1098-1004. ; 42:1, s. 89-101
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Journal article (peer-reviewed)abstract
- Skeletal dysplasias are a heterogeneous group of disorders ranging from mild to lethal skeletal defects. We investigated two unrelated families with individuals presenting with a severe skeletal disorder. In family NMD02, affected individuals had a dysostosis multiplex-like skeletal dysplasia and severe short stature (<-8.5 SD). They manifested increasingly coarse facial features, protruding abdomens, and progressive skeletal changes, reminiscent of mucopolysaccharidosis. The patients gradually lost mobility and the two oldest affected individuals died in their twenties. The affected child in family ID01 had coarse facial features and severe skeletal dysplasia with clinical features similar to mucopolysaccharidosis. She had short stature, craniosynostosis, kyphoscoliosis, and hip-joint subluxation. She died at the age of 5 years. Whole-exome sequencing identified two homozygous variants c.133C>T; p.(Arg45Trp) and c.215dupA; p.(Tyr72Ter), respectively, in the two families, affecting an evolutionary conserved gene TMEM251 (NM_001098621.1). Immunofluorescence and confocal studies using human osteosarcoma cells indicated that TMEM251 is localized to the Golgi complex. However, p.Arg45Trp mutant TMEM251 protein was targeted less efficiently and the localization was punctate. Tmem251 knockdown by small interfering RNA induced dedifferentiation of rat primary chondrocytes. Our work implicates TMEM251 in the pathogenesis of a novel disorder and suggests its potential function in chondrocyte differentiation.
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| 9. |
- Katsanos, Aristeidis H, et al.
(author)
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Blood Pressure After Endovascular Thrombectomy and Outcomes in Patients With Acute Ischemic Stroke: An Individual Patient Data Meta-analysis.
- 2022
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In: Neurology. - 1526-632X. ; 98:3
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Journal article (peer-reviewed)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.
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| 10. |
- Keselman, Boris, et al.
(author)
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Analysis and modelling of mistriage in the Stockholm stroke triage system
- 2022
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In: European Stroke Journal. - : Sage Publications. - 2396-9873 .- 2396-9881. ; 7:2, s. 126-133
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Journal article (peer-reviewed)abstract
- Introduction: The Stockholm Stroke Triage System (SSTS) is a prehospital triage system for detection of patients eligible for endovascular thrombectomy (EVT). Assessment of hemiparesis combined with ambulance-hospital teleconsultation is used to route patients directly to the thrombectomy centre. Some patients are not identified and require secondary transport for EVT (undertriage) while others taken to the thrombectomy centre do not undergo EVT (overtriage). The aims of this study were to characterize mistriaged patients, model for and evaluate alternative triage algorithms.Patients and methods: Patients with suspected stroke transported by priority 1 ground ambulance between October 2017 and October 2018 (n = 2905) were included. Three triage algorithms were modelled using prehospital data. Decision curve analysis was performed to calculate net benefit (correctly routing patients for EVT without increasing mistriage) of alternative models vs SSTS.Results: Undertriage for EVT occurred in n = 35/2582 (1.4%) and overtriage in n = 239/323 (74.0%). Compared to correct thrombectomy triages, undertriaged patients were younger and had lower median NIHSS (10 vs 18), despite 62.9% with an M1 occlusion. In overtriaged patients, 77.0% had a stroke diagnosis (29.7% haemorrhagic). Hemiparesis and FAST items face and speech were included in all models. Decision curve analysis showed highest net benefit for SSTS for EVT, but lower for large artery occlusion (LAO) stroke.Discussion: Undertriaged patients had lower NIHSS, likely due to better compensated proximal occlusions. SSTS was superior to other models for identifying EVT candidates, but lacked information allowing comparison to other prehospital scales.Conclusion: Using prehospital data, alternative models did not outperform the SSTS in finding EVT candidates.
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| 11. |
- Keselman, Boris, et al.
(author)
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The Stockholm Stroke Triage Project : Outcomes of Endovascular Thrombectomy Before and After Triage Implementation
- 2022
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In: Stroke. - : Lippincott Williams & Wilkins. - 0039-2499 .- 1524-4628. ; 53:2, s. 473-481
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Journal article (peer-reviewed)abstract
- BACKGROUND AND PURPOSE: The Stockholm Stroke Triage System (SSTS) is a prehospital algorithm for detection of endovascular thrombectomy (EVT)-eligible patients, combining symptom severity assessment and ambulance-to-hospital teleconsultation, leading to a decision on primary stroke center bypass. In the Stockholm Region (6 primary stroke centers, 1 EVT center), SSTS implementation in October 2017 reduced onset-to-EVT time by 69 minutes. We compared clinical outcomes before and after implementation of SSTS in an observational study.METHODS: We prospectively recruited patients transported by Code Stroke ambulance within the Stockholm region under the SSTS, treated with EVT during October 2017 to October 2019, and compared to EVT patients from 2 previous years.OUTCOMES: shift in modified Rankin Scale (mRS) scores, mRS score 0 to 1, mRS score 0 to 2, and death (all 3 months), National Institutes of Health Stroke Scale (NIHSS) score change 24-hour post-EVT, recanalization (Thrombolysis in Cerebral Infarction 2b-3), and symptomatic intracranial hemorrhage. mRS outcomes were adjusted for age and baseline NIHSS.RESULTS: Patients with EVT in the SSTS group (n=244) were older and had higher baseline NIHSS versus historical controls (n=187): median age 74 (interquartile range, 63-81) versus 71 (61-78); NIHSS score 17 (11.5-21) versus 15 (10-20). During SSTS, median onset-to-puncture time was 136 versus 205 minutes (P<0.001). Adjusted common odds ratio for lower mRS in SSTS patients was 1.7 (95% CI, 1.2-2.3) versus controls. During SSTS, 83/240 (34.6%) versus 44/186 (23.7%) reached 3-month mRS score 0 to 1 (P=0.014), adjusted common odds ratio 2.3 (95% CI, 1.4-3.6). Median NIHSS change 24-hour post-EVT was 6 versus 4 (P=0.005). Differences in Thrombolysis in Cerebral Infarction, symptomatic intracranial hemorrhage, and death were nonsignificant.CONCLUSIONS: With an onset to arterial puncture time reduction by 69 minutes, outcomes in thrombectomy-treated patients improved significantly after region-wide large artery occlusion triage system implementation. These results warrant replication studies in other geographic and organizational circumstances.
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| 12. |
- Lundström, Erik, 1964-, et al.
(author)
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How common is isolated dysphasia among patients with stroke treated with intravenous thrombolysis, and what is their outcome? Results from the SITS-ISTR.
- 2015
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In: BMJ Open. - : BMJ. - 2044-6055. ; 5:11
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Journal article (peer-reviewed)abstract
- OBJECTIVES: To describe the frequency and outcome of isolated dysphasia among patients treated with intravenous thrombolysis (IVT).DESIGN: Patients registered in the SITS International Stroke Thrombolysis Register (SITS-ISTR).PARTICIPANTS: Patients with stroke (N=58,293) treated with IVT between December 2002 and December 2012.SETTING: A multinational, prospective, observational monitoring register.MAIN OUTCOME MEASURES: Isolated dysphasia and modified Rankin Scale (mRS).METHODS: We identified patients presenting with isolated dysphasia by reviewing items within the baseline National Institutes of Health Stroke Scale (NIHSS). We performed descriptive statistics for baseline and demographic data, and reported patients' characteristics, radiological data and changes in their NIHSS score within 7 days and mRS score at 3 months. We also reported corresponding data from the general SITS-ISTR cohort.RESULTS: We found isolated dysphasia at baseline in 1.14% (663/58,293) of all patients treated with IVT patients. Patients with isolated dysphasia had a longer onset to treatment time, lower proportion of visible infarctions on admission imaging scan and atrial fibrillation, and were less often classified as having large vessels causing strokes, in comparison with the rest of the SITS-ISTR. Symptomatic intracerebral haemorrhage occurred in 2.3% of patients per SITS-MOST definition and fatal outcome in 5.5%. At 7 days, 50% of patients with isolated dysphasia recovered completely and at 3 months, 86.3% patients were functionally independent (mRS score 0-2), 71.7% had an excellent outcome (mRS score 0-1) and 45.5% had an mRS score of 0.CONCLUSIONS: A low proportion of patients with isolated dysphasia are treated with IVT. Half of these patients were fully recovered at 7 days.
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| 13. |
- Mazya, Michael V., et al.
(author)
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Implementation of a Prehospital Stroke Triage System Using Symptom Severity and Teleconsultation in the Stockholm Stroke Triage Study
- 2020
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In: JAMA Neurology. - : American Mathematical Society (AMS). - 2168-6149 .- 2168-6157. ; 77:6, s. 691-699
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Journal article (peer-reviewed)abstract
- Importance: To our knowledge, it is unknown whether a prehospital stroke triage system combining symptom severity and teleconsultation could accurately select patients for primary stroke center bypass and hasten delivery of endovascular thrombectomy (EVT) without delaying intravenous thrombolysis (IVT).Objective: To evaluate the predictive performance of the newly implemented Stockholm Stroke Triage System (SSTS) for large-artery occlusion (LAO) stroke and EVT initiation. Secondary objectives included evaluating whether the Stockholm Stroke Triage System shortened onset-to-puncture time for EVT and onset-to-needle time (ONT) for IVT.Design, Setting, and Participants: This population-based prospective cohort study conducted from October 2017 to October 2018 across the Stockholm region (Sweden) included patients transported by first-priority ("code stroke") ambulance to the hospital for acute stroke suspected by an ambulance nurse and historical controls (October 2016-October 2017). Exclusion criteria were in-hospital stroke and helicopter or private transport. Of 2909 eligible patients, 4 (0.14%) declined participation.Exposures: Patients were assessed by ambulance nurses with positive the face-arm-speech-time test or other stroke suspicion and were evaluated for moderate-to-severe hemiparesis (≥2 National Institutes of Health stroke scale points each on the ipsilateral arm and leg [A2L2 test]). If present, the comprehensive stroke center (CSC) stroke physician was teleconsulted by phone for confirmation of stroke suspicion, assessment of EVT eligibility, and direction to CSC or the nearest primary stroke center. If absent, the nearest hospital was prenotified.Main Outcomes and Measures: Primary outcome: LAO stroke. Secondary outcomes: EVT initiation, onset-to-puncture time, and ONT. Predictive performance measures included sensitivity, specificity, positive and negative predictive values, the overall accuracy for LAO stroke, and EVT initiation.Results: We recorded 2905 patients with code-stroke transports (1420 women [49%]), and of these, 323 (11%) had A2L2+ teleconsultation positive results and were triaged for direct transport to CSC (median age, 73 years [interquartile range (IQR), 64-82 years]; 55 women [48%]). Accuracy for LAO stroke was 87% (positive predictive value, 41%; negative predictive value, 93%) and 91% for EVT initiation (positive predictive value, 26%; negative predictive value, 99%). Endovascular thrombectomy was performed for 84 of 323 patients (26%) with triage-positive results and 35 of 2582 patients (1.4%) with triage-negative results. In EVT cases with a known onset time (77 [3%]), the median OPT was 137 minutes (IQR, 118-180; previous year, 206 minutes [IQR, 160-280]; n = 75) (P < .001). The regional median ONT (337 [12%]) was unchanged at 115 minutes (IQR, 83-164; previous year, 115 minutes [IQR, 85-161]; n = 360) (P = .79). The median CSC IVT door-to-needle time was 13 minutes (IQR, 10-18; 116 [4%]) (previous year, 31 minutes [IQR, 19-38]; n = 45) (P < .001).Conclusions and Relevance: The Stockholm Stroke Triage System, which combines symptom severity and teleconsultation, results in markedly faster EVT delivery without delaying IVT.
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| 14. |
- Mazya, Michael V., et al.
(author)
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Remote or extraischemic intracerebral hemorrhage--an uncommon complication of stroke thrombolysis : results from the safe implementation of treatments in stroke-international stroke thrombolysis register
- 2014
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In: Stroke. - : Lippincott Williams & Wilkins. - 0039-2499 .- 1524-4628. ; 45:6, s. 1657-1663
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Journal article (peer-reviewed)abstract
- BACKGROUND AND PURPOSE: Intracerebral hemorrhage after treatment with intravenous recombinant tissue-type plasminogen activator for ischemic stroke can occur in local relation to the infarct, as well as in brain areas remote from infarcted tissue. We aimed to describe risk factors, 3-month mortality, and functional outcome in patients with the poorly understood complication of remote intracerebral hemorrhage, as well as local intracerebral hemorrhage.METHODS: In this study, 43 494 patients treated with intravenous recombinant tissue-type plasminogen activator, with complete imaging data, were enrolled in the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) during 2002 to 2011. Baseline data were compared among 970 patients (2.2%) with remote parenchymal hemorrhage (PHr), 2325 (5.3%) with PH, 438 (1.0%) with both PH and PHr, and 39 761 (91.4%) without PH or PHr. Independent risk factors for all hemorrhage types were obtained by multivariate logistic regression.RESULTS: Previous stroke (P=0.023) and higher age (P<0.001) were independently associated with PHr, but not with PH. Atrial fibrillation, computed tomographic hyperdense cerebral artery sign, and elevated blood glucose were associated with PH, but not with PHr. Female sex had a stronger association with PHr than with PH. Functional independence at 3 months was more common in PHr than in PH (34% versus 24%; P<0.001), whereas 3-month mortality was lower (34% versus 39%; P<0.001).CONCLUSIONS: Differences between risk factor profiles indicate an influence of previous vascular pathology in PHr and acute large-vessel occlusion in PH. Additional research is needed on the effect of pre-existing cerebrovascular disease on complications of recanalization therapy in acute ischemic stroke.
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| 15. |
- Soomro, Shafiullah, et al.
(author)
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Selective image segmentation driven by region, edge and saliency functions
- 2023
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In: PLOS ONE. - : Public Library of Science. - 1932-6203. ; 18:12
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Journal article (peer-reviewed)abstract
- Present active contour methods often struggle with the segmentation of regions displaying variations in texture, color, or intensity a phenomenon referred to as inhomogeneities. These limitation impairs their ability to precisely distinguish and outline diverse components within an image. Further some of these methods employ intricate mathematical formulations for energy minimization. Such complexity introduces computational sluggishness, making these methods unsuitable for tasks requiring real-time processing or rapid segmentation. Moreover, these methods are susceptible to being trapped in energy configurations corresponding to local minimum points. Consequently, the segmentation process fails to converge to the desired outcome. Additionally, the efficacy of these methods diminishes when confronted with regions exhibiting weak or subtle boundaries. To address these limitations comprehensively, our proposed approach introduces a fresh paradigm for image segmentation through the synchronization of region-based, edge-based, and saliency-based segmentation techniques. Initially, we adapt an intensity edge term based on the zero crossing feature detector (ZCD), which is used to highlight significant edges of an image. Secondly, a saliency function is formulated to detect salient regions from an image. We have also included a globally tuned region based SPF (signed pressure force) term to move contour away and capture homogeneous regions. ZCD, saliency and global SPF are jointly incorporated with some scaled value for the level set evolution to develop an effective image segmentation model. In addition, proposed method is capable to perform selective object segmentation, which enables us to choose any single or multiple objects inside an image. Saliency function and ZCD detector are considered feature enhancement tools, which are used to get important features of an image, so this method has a solid capacity to segment nature images (homogeneous or inhomogeneous) precisely. Finally, the adaption of the Gaussian kernel removes the need of any penalization term for level set reinitialization. Experimental results will exhibit the efficiency of the proposed method.
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| 16. |
- Wahlgren, Nils, et al.
(author)
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Multivariable Analysis of Outcome Predictors and Adjustment of Main Outcome Results to Baseline Data Profile in Randomized Controlled Trials Safe Implementation of Thrombolysis in Stroke-MOnitoring STudy (SITS-MOST)
- 2008
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In: Stroke. - 0039-2499 .- 1524-4628. ; 39:12, s. 3316-3322
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Journal article (peer-reviewed)abstract
- Background and Purpose-The Safe Implementation of Thrombolysis in Stroke-MOnitoring STudy (SITS-MOST) unadjusted results demonstrated that intravenous alteplase is well tolerated and that the effects were comparable with those seen in randomized, controlled trials (RCTs) when used in routine clinical practice within 3 hours of ischemic stroke onset. We aimed to identify outcome predictors and adjust the outcomes of the SITS-MOST to the baseline characteristics of RCTs.Methods-The study population was SITS-MOST (n=6483) and pooled RCTs (n=464) patients treated with intravenous alteplase within 3 hours of stroke onset. Multivariable, backward stepwise regression analyses (until P <= 0.10) were performed to identify the outcome predictors for SITS-MOST. Variables appearing either in the final multivariable model or differing (P < 0.10) between SITS-MOST and RCTs were included in the prediction model for the adjustment of outcomes.Main outcome measures were symptomatic intracerebral hemorrhage, defined as National Institutes of Health Stroke Scale deterioration >= 1 within 7 days with any hemorrhage (RCT definition), mortality, and independency as defined by modified Rankin Score of 0 to 2 at 3 months.Results-The adjusted proportion of symptomatic intracerebral hemorrhage for SITS-MOST was 8.5% (95% CI, 7.9 to 9.0) versus 8.6% (6.3 to 11.6) for pooled RCTs; mortality was 15.5% (14.7 to 16.2) versus 17.3% (14.1 to 21.1); and independency was 50.4% (49.6 to 51.2) versus 50.1% (44.5 to 54.7), respectively. In the multivariable analysis, older age, high blood glucose, high National Institutes of Health Stroke Scale score, and current infarction on imaging scans were related to poor outcome in all parameters. Systolic blood pressure, atrial fibrillation, and weight were additional predictors of symptomatic intracerebral hemorrhage. Current smokers had a lower rate of symptomatic intracerebral hemorrhage. Disability before current stroke (modified Rankin Score 2 to 5), diastolic blood pressure, antiplatelet other than aspirin, congestive heart failure, patients treated in new centers, and male sex were related to high mortality at 3 months.Conclusions-The adjusted outcomes from SITS-MOST were almost identical to those in relevant RCTs and reinforce the conclusion drawn previously in the unadjusted analysis. We identified several important outcome predictors to better identify patients suitable for thrombolysis.
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