Acute Ischemic and Hemorrhagic Cerebrovascular Strokes After Cardiac Surgery: Incidence, Predictors, and Outcomes.

The global and regional burden of stroke.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Does concurrent use of intra-aortic balloon pump (IABP) improve survival in patients with cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO)?'. Altogether 472 papers were found using the reported search, of which 3 level 2 systematic reviews represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The reported comparative outcomes were mortality, weaning off extracorporeal membrane oxygenation (ECMO), vascular complications and non-vascular complications. One systematic review demonstrated significantly lower in-hospital mortality with concurrent use of IABP and VA-ECMO, while the other 2 studies showed no difference in mortality. One paper reported on the weaning success from ECMO and demonstrated significantly higher weaning success with concurrent IABP usage. Another paper reported on the complications and showed no differences in vascular and non-vascular complications. We conclude that there was no significant improvement in survival with the concurrent use of IABP and VA-ECMO for a cardiogenic shock as compared to the use of VA-ECMO alone. However, the concurrent use of IABP with VA-ECMO improved weaning success from VA-ECMO. The incidence of vascular and non-vascular complications was similar with or without IABP usage.

Adults with congenital heart disease (CHD) are at increased risk of stroke but high-quality population level data on stroke incidence in these patients are scant. A retrospective whole-population Western Australian cohort of adultpatients with CHD aged 18 to 64 years was created and followed from January 2000 to December 2017 using linked hospital data. Stroke incidence rates within the adult cohort with CHD were calculated and compared with the general population via direct standardization. A nested case-control design assessed predictors of ischemic and hemorrhagic stroke within the cohort. Among 7916 adults with CHD, 249 (3.1%) incident strokes occurred at a median age of 47 years; 186 (2.3%) ischemic, 33 (0.4%) hemorrhagic and 30 (0.4%) unspecified strokes. Ischemic and hemorrhagic stroke incidence was, respectively, 9 and 3 times higher in adults with CHD than the general population. Absolute risk was low with annual rates of 0.26% (ischemic) and 0.05% (hemorrhagic). Highest rates were observed in adults with shunt and left-sided lesions. Predictors of ischemic stroke in adults with CHD included recent cardiac surgery, left-sided valve repair/replacements, shunt lesions, and traditional risk factors (hypertension, infective endocarditis, peripheral vascular disease, and tobacco use). Mental health disorders and increasing Charlson's comorbidity scores were strongly associated with higher risk of ischemic and hemorrhagic stroke. The CHA2DS2VASc score was associated with ischemic stroke incidence. This study provides the first population-based stroke incidence estimates for adults with CHD in Australia, showing elevated stroke risk across different CHD lesions. It highlights the potential clinical importance of managing comorbidities, especially mental health.

Introduction: The time course and risk of hemorrhagic and ischemic stroke following left ventricular assist device (LVAD) placement is not well described. Hypothesis: Ischemic and hemorrhagic stroke are major causes of mortality following LVAD placement. Methods: Prospectively collected data of Heartmate II (N=335) and Heartware (N=70) LVAD patients from a single center were reviewed from 10/21/2004-5/19/2015. Patients were followed until transplant or death. Predictors of ischemic and hemorrhagic stroke (ICH, SAH, SDH) occurring during hospitalization for LVAD placement (early stroke) or in follow-up (late stroke) were assessed using Chi-squared or Mann-Whitney U tests. The association of stroke and mortality was assessed using multivariable logistic regression analysis. Results: Of 405 patients, stroke occurred in 69 (17%). Early ischemic and hemorrhagic stroke occurred in 18 (4.4%) and 11 (2.7%) patients, respectively. Late ischemic and hemorrhagic stroke occurred in 25 (6.2%) and 29 (7.2%) patients, respectively and 11 (3%) had more than one stroke. ICH was the most common type of hemorrhagic stroke (N=23). History of implanted cardioverter defibrillator, tobacco use, poor NYHA class and hypertension post-LVAD significantly predicted ischemic stroke, while history of hypertension and arrhythmia predicted hemorrhagic stroke (all P<0.05). Stroke was the leading primary cause of death in 17% of LVAD patients (second only to multi-system organ failure [21%]). Most deaths were related to late ischemic stroke (N=9/150, 6%), or late hemorrhagic stroke (N=15/150, 10%), while only 2 (1%) died from early stroke. After adjusting for age, NYHA class, and LVAD type, late ischemic stroke (adjusted odds ratio [aOR] 8.8, 95% CI 3.3-23.5, P<0.0001) and late hemorrhagic stroke (aOR 9.7, 95% CI 4.0-23.4, P<0.0001) predicted death, while early ischemic or hemorrhagic stroke did not. Conclusions: Stroke is a leading cause of death in LVAD patients. Late ischemic and hemorrhagic stroke have a greater impact on mortality than early stroke. Management of risk factors, such as hypertension post LVAD, may reduce stroke and mortality rates.

Combined use of venoarterial extracorporeal membrane oxygenation and intra-aortic balloon pump after cardiac arrest

Intracerebral hemorrhage (ICH) is the second most common cause of stroke and accounts for 8% to 15% of strokes in Western societies with an estimated incidence of 10 to 25 per 100 000 persons.1–3 Despite advances in the field of stroke and neurocritical care,4 the 30-day mortality has not changed significantly over the past 20 years.3 Indeed, ICH has the highest rates of dependence or death among stroke types and proven treatments are lacking. Clinical trials aimed at limiting hemorrhage growth, procoagulant agents for hemostasis,5 and surgical evacuation6 have not translated into improved clinical outcomes. Antihypertensive therapy for the purpose of reducing hematoma growth has been a mainstay of acute management. Guidelines recommend maintaining mean arterial pressure <130 mm Hg during the acute phase7; however, controversies exist given the lack of randomized clinical trial data and uncertainties about the rapidity and target level of blood pressure (BP)-lowering. Recent Phase 2 clinical trials evaluating acute BP control have shown promise in reducing hematoma expansion with an adequate safety profile and Phase 3 trials are underway.8,9 Besides hematoma growth, other pathophysiological processes occur in the setting of ICH and may serve as potential therapeutic targets. In the acute period after ICH, a rapid rise in intracranial pressure (ICP) from an expanding hematoma may reduce cerebral perfusion pressure. In this setting, interventions aimed at BP-lowering and hemostasis may theoretically induce thrombosis or exacerbate brain ischemia, particularly in patients with pre-existing cerebrovascular disease. A recent publication suggests that aggressive BP-lowering may actually cause acute brain ischemia and worsen outcomes after ICH.10 In this review, we outline the data on secondary acute ischemic injury after ICH, review the prevalence of remote ischemic lesions and risk factors associated with their occurrence, explore potential …

Advances in Neurocardiology: Focus on Atrial Fibrillation.

Stroke has been reported in observational series as a frequent complication of coronavirus disease 2019, but more information is needed regarding stroke prevalence and outcomes. We explored the prevalence and outcomes of acute stroke in an international cohort of patients with coronavirus disease 2019 who required ICU admission. Retrospective analysis of prospectively collected database. A registry of coronavirus disease 2019 patients admitted to ICUs at over 370 international sites was reviewed for patients diagnosed with acute stroke during their stay. Patients older than 18 years old with acute coronavirus disease 2019 infection in ICU. None. Of 2,699 patients identified (median age 59 yr; male 65%), 59 (2.2%) experienced acute stroke: 0.7% ischemic, 1.0% hemorrhagic, and 0.5% unspecified type. Systemic anticoagulant use was not associated with any stroke type. The frequency of diabetes, hypertension, and smoking was higher in patients with ischemic stroke than in stroke-free and hemorrhagic stroke patients. Extracorporeal membrane oxygenation support was more common among patients with hemorrhagic (56%) and ischemic stroke (16%) than in those without stroke (10%). Extracorporeal membrane oxygenation patients had higher cumulative 90-day probabilities of hemorrhagic (relative risk = 10.5) and ischemic stroke (relative risk = 1.7) versus nonextracorporeal membrane oxygenation patients. Hemorrhagic stroke increased the hazard of death (hazard ratio = 2.74), but ischemic stroke did not-similar to the effects of these stroke types seen in noncoronavirus disease 2019 ICU patients. In an international registry of ICU patients with coronavirus disease 2019, stroke was infrequent. Hemorrhagic stroke, but not ischemic stroke, was associated with increased mortality. Further, both hemorrhagic stroke and ischemic stroke were associated with traditional vascular risk factors. Extracorporeal membrane oxygenation use was strongly associated with both stroke and death.

Establishing new approaches for the prevention and treatment of stroke relies on identifying modifiable risk factors that contribute to the development of this complex disease. Mendelian randomization (MR) studies, analogous to naturally occurring randomized trials, can assess causality of potentially modifiable biomarkers and offer new insights into biological pathways. Stroke is the second leading cause of death worldwide and the chief determinant of long-term disability. Stroke is a heterogeneous disease arising from several distinct underlying pathologies and is typically classified as ischemic or hemorrhagic, and further subclassified using imaging data. Ischemic stroke (IS), including its 3 main subtypes: small vessel disease, large vessel disease, and cardioembolic stroke, accounts for ≈80% of stroke and is the result of an interrupted blood supply, leading to localized areas of ischemia in the brain. Small vessel disease may be a consequence of nonatherosclerotic, as well as atherosclerotic, mechanisms that result in an occlusion of the small perforating arteries, whereas large vessel disease results from occlusions or emboli from plaque rupture in larger vessels, such as a carotid artery. Cardioembolic stroke arises typically from emboli from the heart. By contrast, hemorrhagic stroke is a consequence of intracerebral hemorrhage (bleeding into the brain) or subarachnoid hemorrhage (bleeding into the subarachnoid space). These diverse stroke subtypes have distinct underlying pathologies reflecting different risk factor distributions. MR studies, using genetic variants as instrumental variables, afford a powerful approach to assessing causality of risk factors and avoid biases inherent in observational studies, including confounding and reverse causation. This review considers the contribution of MR studies to stroke epidemiology and their relevance to understanding risk factors and new therapeutic targets for stroke. Meta-analyses of large prospective studies have enhanced our knowledge of classical and emerging risk factors for stroke.1–4 Classical risk factors for stroke include nonmodifiable characteristics, …

Background Stroke is considered as a life threatening case in neurological patients. It is one of the leading causes of morbidity and mortality worldwide, as cerebrovascular accidents rank first in the frequency and importance among all neurological disease. Spontaneous ICH accounts for approximately 20% of all strokes, and it is characterized by high rates of mortality and residual disability among survivors. Aim of the Work To detect the value of serum CRP level in differentiation between ischemic and hemorrhagic stroke. Patients and Methods We conducted a prospective cross section study which included patients who were diagnosed with acute stroke through the period Jan 2021 and July 2021, we recruited 72 patients who were admitted to stroke unit of Ain shams university, they were subsequently divided based on etiology of the stroke into 2 groups: Ischemic stroke group: 36 patients and hemorrhagic stroke group: 36 patients. Results We conducted a cross section analytical study to compare the CRP level among egyptian cohort of patients (n = 72) who were diagnosed with acute ischemic (n = 36) versus hemorrhagic strokes (n = 36) who were admitted to emergency of Ain shams university, aiming to detect the value of serum CRP level in differentiation between ischemic and hemorrhagic stroke. In the present study we found that there was a statistically significant difference between the studied groups and CRP on day 0, mean CRP during Hospital Stay and CRP at discharge. Conclusion Elevated CRP levels are associated with excessive risk of ischemic stroke but not hemorrhagic stroke. The serum CRP level can be used as a predictor for ischemic stroke in the general population.

The risk factors for recurrence of hemorrhagic or ischemic stroke in patients with intracranial hemorrhage (ICH) are inconclusive. This study was designed to investigate the risk factors for stroke recurrence and the impact of antiplatelet on stroke recurrence in patients with ICH. This population-based case-cohort study analyzed the data obtained from a randomized sample of 2 million subjects in the Taiwan National Health Insurance Research Database. The survival of patients with hemorrhagic stroke from January 1, 2000, to December 31, 2013, was included in the study. During the 5-year follow-up period, the recurrence rate of stroke was 13.1% (7.01% hemorrhagic stroke, and 6.12% ischemic stroke). The recurrence rate of stroke was 13.3% in the without antiplatelet group and 12.6% in the antiplatelet group. The risk factor for hemorrhagic stroke was hypertension (OR 1.87). The risk factors for ischemic stroke were age (OR 2.99), diabetes mellitus (OR 1.28), hypertension (OR 2.68), atrial fibrillation (OR 1.97), cardiovascular disease (OR 1.42), and ischemic stroke history (OR 1.68). Antiplatelet may decrease risk of hemorrhagic stroke (OR 0.53). The risk of stroke recurrence is high in patients with ICH. Hypertension is a risk factor for ischemic and hemorrhagic stroke recurrence. Antiplatelet therapy does not decrease risk of ischemic stroke recurrence but may reduce recurrence of hemorrhagic stroke.

BackgroundThe relative risk of ischemic stroke (IS) in head and neck cancer (HNC) patients developing carotid artery stenosis (CAS) or vertebral artery stenosis (VAS) after radiation therapy (RT) remains uncertain due to limited studies, complicating vascular follow-ups and preventive strategies.MethodsWe included HNC patients who received RT between 2010 and 2023. The patients were divided into nasopharyngeal carcinoma (NPC) and non-NPC groups. The primary outcome was the occurrence of IS after RT, and the secondary outcomes included the development of > 50% CAS or > 50% VAS after RT.ResultsOf the 1,423 HNC patients, there were 19% of patients developed > 50% CAS, 6.8% of patients developed > 50% VAS, and 2.3% of patients developed IS. In patients with HNC, > 50% CAS (adjusted hazard ratio [HR] = 3.21, 95% confidence interval [CI] = 1.53–6.71), and > 50% VAS (adjusted HR = 2.89, 95% CI = 1.28–6.53) were both the independent predictors of IS. In the patients with NPC, > 50% CAS was an independent predictor of anterior circulation IS (adjusted HR = 4.39, 95% CI = 1.17–16.47). By contrast, > 50% VAS emerged as a predictor of posterior circulation IS in both the NPC (adjusted HR = 15.02, 95% CI = 3.76–60.06) and non-NPC groups (adjusted HR = 13.59, 95% CI = 2.21–83.46).ConclusionHNC patients with > 50% CAS or > 50% VAS after RT had an increased risk of IS within their corresponding vascular territory. CAS could be an important predictor of IS in NPC patients, whereas VAS might also be a significant predictor of IS in both NPC and non-NPC patients. Evaluation both the carotid and vertebral arteries after RT might be necessary.Trial registrationClinicalTrials.gov identifier No.: NCT06111430.

Background: Neonatal stroke occurs in an estimated 1 in 3000 live births and is the most common cause of hemiplegic cerebral palsy in term infants. Most population based studies on neonatal stroke in the past have been single center or regional, focused only on ischemic stroke, and with less than 100 cases. Large administrative datasets can provide information on comorbid perinatal conditions in neonatal stroke. Methods: Data for patients aged 0-28 days with a diagnosis of either ischemic or hemorrhagic stroke (either subarachnoid or intracerebral hemorrhage) were extracted from the Cerner Health Facts EMR database from 2000-2018. Incidence of birth demographics, perinatal complications, anti-epileptic use, and aspirin use was assessed. Odds ratios were calculated against a cohort of neonates without stroke. Results: Among 1,591,104 neonates in the Cerner EMR database, 452 (59%) neonates were identified with ischemic stroke and 311 (41%) with hemorrhagic stroke. The most common comorbidities for ischemic stroke were neonatal sepsis (16%, OR=13.1), head and scalp birth injury (13%, OR=7.1) and hypoxic injury (12%, OR=38.7). The most common comorbidities for hemorrhagic stroke were head and scalp birth injury (30%, OR=19.5), prematurity (26%, OR=4.2) and neonatal sepsis (23%, OR=13.1). Procedure codes for intubation, neonatal resuscitation, and epinephrine use were prominent in both hemorrhagic (15.1%, OR=35) and ischemic stroke (8.9%, OR=19.1). The proportion of hemorrhagic and ischemic stroke patients receiving antiepileptics was 23% and 27%, respectively. The proportion of ischemic stroke patients who received aspirin was 16.4%. Conclusion: This population based study of neonatal stroke, the largest of its kind, demonstrated a wide variety of comorbid conditions with ischemic and hemorrhagic stroke. Antiepileptic use is common in neonatal ischemic stroke, though in our population-based study of both academic and non-academic centers the prevalence is less than prior estimates. Sepsis, head and scalp injuries, prematurity, and hypoxic injury are associated with neonatal hemorrhagic and ischemic stroke, though prevalence varies between types. More study is needed on specific risk factors and pathogenesis in neonatal stroke.

Although acute brain injury is common in patients receiving extracorporeal membrane oxygenation, little is known regarding the mechanism and predictors of ischemic and hemorrhagic stroke. We aimed to determine the risk factors and outcomes of each ischemic and hemorrhagic stroke in patients with venoarterial extracorporeal membrane oxygenation support. Retrospective analysis. Data reported to the Extracorporeal Life Support Organization by 310 extracorporeal membrane oxygenation centers from 2013 to 2017. Patients more than 18 years old supported with a single run of venoarterial extracorporeal membrane oxygenation. None. Of 10,342 venoarterial extracorporeal membrane oxygenation patients, 401 (3.9%) experienced ischemic stroke and 229 (2.2%) experienced hemorrhagic stroke. Reported acute brain injury during venoarterial extracorporeal membrane oxygenation decreased from 10% to 6% in 5 years. Overall in-hospital mortality was 56%, but rates were higher when ischemic stroke and hemorrhagic stroke were present (76% and 86%, respectively). In multivariable analysis, lower pre-extracorporeal membrane oxygenation pH (adjusted odds ratio, 0.21; 95% CI, 0.09-0.49; p < 0.001), higher PO2 on first day of extracorporeal membrane oxygenation (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; p = 0.009), higher rates of extracorporeal membrane oxygenation circuit mechanical failure (adjusted odds ratio, 1.33; 95% CI, 1.02-1.74; p = 0.03), and renal replacement therapy (adjusted odds ratio, 1.49; 95% CI, 1.14-1.94; p = 0.004) were independently associated with ischemic stroke. Female sex (adjusted odds ratio, 1.61; 95% CI, 1.16-2.22; p = 0.004), extracorporeal membrane oxygenation duration (adjusted odds ratio, 1.01; 95% CI, 1.00-1.03; p = 0.02), renal replacement therapy (adjusted odds ratio, 1.81; 95% CI, 1.30-2.52; p < 0.001), and hemolysis (adjusted odds ratio, 1.87; 95% CI, 1.11-3.16; p = 0.02) were independently associated with hemorrhagic stroke. Despite a decrease in the prevalence of acute brain injury in recent years, mortality rates remain high when ischemic and hemorrhagic strokes are present. Future research is necessary on understanding the timing of associated risk factors to promote prevention and management strategy.

BackgroundVenoarterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving mechanical support in patients with cardiogenic shock. There are great variations in the reported rates of neurological complications and associated mortality. Our aim was to analyze our cohort of adult patients supported with VA-ECMO to identify the incidence, outcomes, and predictors of acute ischemic and hemorrhagic strokes.MethodsA total of 195 patients between January 2016 and January 2023 were reviewed, 22 (11.3%) ECPR patients were excluded, and 173 (88.7%) patients were analyzed. We divided the patients into stroke and nonstroke groups according to the presence of radiologically confirmed acute ischemic and hemorrhagic strokes.ResultsThirty-five (20.2%) patients had acute cerebrovascular strokes. 13 (7.5%) patients had intracranial hemorrhage (ICH) while 22 (12.7%) patients had ischemic stroke. The median age was 48 years (IQR: 31, 56), 98 (56.6%) patients were males, and 152 (87.9%) patients had cardiac surgeries. The patients who developed cerebrovascular stroke had higher blood lactate at ECMO initiation (8.9 [5.5, 11.2] versus 5.7 [4.6, 11.9] mmol/L, p = 0.02) and 12 h later (8.7 [4.7, 14.5] versus 5.8 [4.6, 15] mmol/L, p = 0.024) with lesser lactate clearance (LC) at 12 h (6.35 [−51.5, 40.6] versus 14.65% [−43.55, 38.3], p < 001) compared to the patients in the nonstroke group. The stroke group had longer ICU stay (21 vs. 15.5 days, p = 0.03), higher frequency of new hemodialysis (62.9% vs. 46.4%, p = 0.026), and on-ECMO mortality (54.3% vs. 44.9%, p = 0.041) compared with the nonstroke group. The ICH was associated with higher hospital mortality (p = 0.021) compared to the ischemic stroke. Logistic multivariate regression revealed that the initial lactate level (OR: 1.6, 95% CI: 1.2–8.92, p = 0.031), cardiopulmonary bypass time (OR:1.8, 95% CI: 1.32–6.42, p = 0.02), and LC at 12 h (OR: 2.4, 95% CI: 1.91–17.4, p = 0.042) were associated with ischemic stroke. Thrombocytopenia (OR: 3.22, 95% CI: 1.82–7.83, p = 0.001) and low body mass index (OR: 2.1, 95% CI: 1.31–4.6, p = 0.02) were associated with ICH.ConclusionsIschemic and hemorrhagic strokes are frequent with VA-ECMO support and associated with worse outcomes, especially the hemorrhagic type. Awareness of the incidence and the factors associated with strokes is crucial in early identification and management.