American Heart Association/American Stroke Association Research Articles

Association of functional outcomes between intravenous tirofiban and endovascular thrombectomy in imaging-screened patients with large vessel occlusion stroke: a secondary analysis of randomized clinical trial.

In the RESCUE BT (Endovascular Treatment With versus Without Tirofiban for Stroke Patients with Large Vessel Occlusion) trial, enrollment in extended time window was based on non-contrast computed tomography. To assess whether perioperative intravenous tirofiban would further enhance the clinical benefit of endovascular therapy in the RESCUE BT trial according to advanced imaging criteria based on current American Heart Association/American Stroke Association (AHA/ASA) guidelines. This is a secondary analysis of the RESCUE BT trial. Patients who were eligible for endovascular thrombectomy in the 6-hour window and met the criteria of the DAWN or DEFUSE 3 trials in the extended window according to the AHA/ASA guidelines were analyzed. The primary outcome was the distribution of the 90-day modified Rankin Scale (mRS) scores. Safety outcomes included the incidence of symptomatic intracranial hemorrhage (sICH) within 48 hours and 90-day mortality. A total of 652 patients (319 in tirofiban group and 333 in placebo group) who meeting the AHA/ASA guidelines were included in this analysis, with median (IQR) age of 68 (58-75) years, 278 (42.6%) were women. The median 90-day mRS score was 3 (IQR, 1-4) in the tirofiban group, and 3 (IQR, 1-4) in the placebo group. The adjusted common odds ratio (OR) for a lower level of disability with tirofiban than with placebo was 1.08 (95% confidence interval [CI], 0.83-1.42). The incidence of sICH (10.1% versus 6.3%; adjusted OR 1.70; [95% CI, 0.95-3.04]) was not significantly different between groups. However, intravenous tirofiban might be associated with lower disability level (adjusted common OR, 1.74 [95% CI, 1.14-2.65]; P=0.01) in patients with large artery atherosclerosis. There was no significant difference in the severity of disability at 90 days with intravenous tirofiban compared to placebo in patients who underwent endovascular therapy according to AHA/ASA guidelines. We observed potential benefits of tirofiban in patients with large artery atherosclerosis, but there was an increased risk of sICH in patients with cardioembolism stroke.

The AHA/ASA and DSM-V diagnostic criteria for vascular cognitive impairment identify cases with predominant vascular pathology.

There are major challenges in determining the etiology of vascular cognitive impairment (VCI) clinically, especially in the presence of mixed pathologies, such as vascular and amyloid. Most recently, two criteria (American Heart Association/American Stroke Association (AHA/ASA) and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)) have been proposed for the clinical diagnosis of VCI but have not as yet been validated using neuroimaging. This study aims to determine whether the AHA/ASA and DSM-V criteria for VCI can distinguish between cases with predominantly vascular pathology and cases with mixed pathology. A total of 186 subjects were recruited from a cross-sectional memory clinic-based study at the National University Hospital, Singapore. All subjects underwent clinical and neuropsychological assessment, magnetic resonance imaging (MRI) and carbon 11-labeled Pittsburgh Compound B ([11C] PiB) positron emission tomography (PET) scans. Diagnosis of the etiological subtypes of VCI (probable vascular mild cognitive impairment (VaMCI), possible VaMCI, non-VaMCI, probable vascular dementia (VaD), possible VaD, non-VaD) were performed following AHA/ASA and DSM-V criteria. Brain amyloid burden was determined for each subject with standardized uptake value ratio (SUVR) values ⩾1.5 classified as amyloid positive. Using κ statistics, both criteria had excellent agreement for probable VaMCI, probable VaD, and possible VaD (κ = 1.00), and good for possible VaMCI (κ = 0.71). Using the AHA/ASA criteria, the amyloid positivity of probable VaMCI (3.8%) and probable VaD (15%) was significantly lower compared to possible VaMCI (26.7%), non-VaMCI (33.3%), possible VaD (73.3%), and non-VaD (76.2%) (p < 0.001). Similarly, using the DSM-V criteria, the amyloid positivity of probable VaMCI (3.8%) and probable VaD (15%) was significantly lower compared to possible VaMCI (26.3%), non-VaMCI (32.1%), possible VaD (73.3%), and non-VaD (76.2%) (p < 0.001). In both criteria, there was good agreement in differentiating individuals with non-VaD and possible VaD, with significantly higher (p < 0.001) global [11C]-PiB SUVR, from individuals with probable VaMCI and probable VaD, who had predominant vascular pathology. The AHA/ASA and DSM-V criteria for VCI can identify VCI cases with little to no concomitant amyloid pathology, hence supporting the utility of AHA/ASA and DSM-V criteria in diagnosing patients with predominant vascular pathology. Data supporting this study are available from the Memory Aging and Cognition Center, National University of Singapore. Access to the data is subject to approval and a data sharing agreement due to University policy.

An empirical analysis of process improvement from best practice adoption: A study of stroke care best practices

AbstractThis study empirically examines how induced learning through adopting a set of best practices and learning‐by‐doing improved a hospital's care of ischemic stroke patients using ad hoc teams. While previous studies in healthcare operations management conducted in ad hoc team environments predominantly focused on volume‐based learning (learning by doing, team familiarity via interactions among team members), our study focuses on induced learning in ad hoc teams through best practice adoptions. The analysis uses secondary data (Data period: January 2009–March 2017) about stroke patients from a comprehensive stroke center (CSC) in a U.S. tertiary teaching hospital as it adopted the U.S. American Heart Association/American Stroke Association (AHA/ASA) Target:Stroke best practices. The ad hoc stroke teams provide the initial care and their performance is measured using “Door‐to‐Needle (DTN)” time and its sub‐time segments. The DTN time is measured as the time elapsed between the stroke patient's arrival at the hospital's emergency department (ED) and the appropriate infusion of “Tissue Plasminogen Activator (TPA)” (i.e., a thrombolytic medication informally referred to as a “clot buster”). We found that adopting these best practices improved ischemic stroke care beyond improvement due to repetition. We also found that the neurologist's recent experience providing stroke care for the prior patient is positively associated with meeting the time performance goal for the current patient. This study provides insights into the use of management mechanisms to adopt and sustain best practices in healthcare that are generalizable to other organizations with ad hoc team environments.

Abstract 32: Escape Room Activity Improves Nurses’ Knowledge of Stroke Clinical Practice Guidelines

Background: Patients receiving care from stroke specialized nurses have better outcomes. In 2021, the American Heart Association/American Stroke Association (AHA/ASA) published updates to the Comprehensive Nursing Care Scientific Statements providing new evidence and best nursing practices in stroke care. Nursing leadership at a Comprehensive Stroke Center identified this as an opportunity to utilize the Nursing Care Scientific Statements and other AHA/ASA stroke clinical practice guidelines (CPG) to optimize stroke program education and improve quality of nursing care. Purpose: The purpose of this study was to determine whether an escape room activity significantly increases knowledge of stroke CPGs and best nursing care practices and to assess nurses’ confidence in their application when compared to viewing online modules alone. Methods: Based on a literature review and learning needs assessment, nine escape room puzzles were developed spanning the continuum of stroke care. Each puzzle required the application of a CPG or scientific statement to a patient scenario. A variety of materials were used to develop the puzzles, including black lights, locks, jigsaw puzzles, and a custom learning environment in EPIC. Participants submitted a pre- and post-survey to capture qualitative and quantitative data regarding the nurse’s knowledge of and confidence in applying stroke CPGs and best practices. A paired two-sided T-test was conducted using a confidence interval of 95% and sample size of 75 to determine whether the post-survey increase in nurse knowledge and confidence was significant. Results: For all five Likert items, the p-value was less than 0.05, indicating a statistically significant improvement in nurses’ knowledge of and confidence in applying stroke CPGs and best practices. The qualitative data demonstrated a learner preference for the interactive nature of the escape room and the teamwork and critical thinking that it fostered. Conclusion: In conclusion, there was a statistically significant increase in nurse confidence and knowledge of comprehensive nursing stroke care and stroke CPGs after the escape room intervention. This suggests that escape room activities can be an effective way to develop clinical knowledge in stroke nursing.

Abstract 48: Early Carotid Endarterectomy and Carotid Artery Stent Placement in Symptomatic Patients With Internal Carotid Artery Stenosis

Background: The American Heart Association/American Stroke Association (AHA/ASA) 2021 guidelines state that in patients in whom revascularization is planned within 1 week of the index stroke, it is reasonable to choose carotid endarterectomy (CEA) over carotid artery stent placement (CAS) to reduce the periprocedural stroke rate (level of evidence 2A, weak evidence, [B-R] moderate quality data). Objective: To compare the 1-month stroke, myocardial infarction (MI), and/or death rates among symptomatic patients undergoing either CAS or CEA according to the timing of the procedure in Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Methods: We analyzed the effect of CAS and CEA on the rates of 1-month stroke, MI, and/or death after adjusting age, gender, presenting symptom (transient ischemic attack [TIA], retinal ischemia, or minor ischemic stroke), severity of stenosis (50-69% and 70-99%), and timing of procedure (≤7 days and &gt;7 days post qualifying event) using multivariate analysis. Results: The rate of 1-month stroke, MI, and/or death was higher (non-significant) in patients who underwent CAS compared with those who underwent CEA within ≤7 days post-qualifying event (8 of 157 [5.1%] versus 3 of 124 [2.4%], p=0.251). In the multivariate analysis, there was no difference in the odds of 1-month stroke, MI, and/or death in patients who underwent CEA compared with those who underwent CAS (odds ratio [OR] 0.57, 95% CI 0.26-1.20, p=0.15). There was no effect of the timing of the procedure (OR 1.19,95% CI 0.48-3.47, p=0.72). The interaction term between CEA versus CAS and the timing of the procedure was not significant (OR 1.69, 95% 0.21-36.31 CI p=0.66). The only significant factors associated with decreased odds of 1-month stroke, MI, and/or death were the qualifying event of TIA (OR 0.13, 95% CI 0.02-0.57, p=0.02) and retinal ischemic event (OR 0.13, 95% CI 0.01-0.63, p=0.02). Conclusions: In our analysis, we did not identify any increase in odds of a 1-month stroke, MI, and/or death rate with CAS compared with CEA according to the timing of the procedure. Qualifying event characteristics rather than the timing of procedure appeared to be the most determinant, highlighting the need to revisit the recommendations in the AHA/ASA guidelines.

Mechanical thrombectomy for AIS from large vessel occlusion – current trends and future perspectives

Stroke is found to be one of the global top causes of mortality and the major factor in years of life with a handicap (DALYs). Ischemic strokes contributed to nearly 70% of all strokes worldwide. For endovascular thrombectomy in acute ischemic stroke with large vessel obstruction (AIS-LVO), using stent retrievers and/or reperfusion catheters has become the gold standard of therapy. The methodology involved keyword-based search in databases like PubMed, Embase, and Google Scholar for recent publications on mechanical thrombectomy (MT), AIS, large vessel occlusion (Large Vessel Occlusion (LVO)), screening relevant articles, retrieving full texts, and synthesizing key findings on procedural advancements, patient selection, COVID-19 (coronavirus disease 2019) impact, delay effects, effectiveness, clinical outcomes, and future perspectives. Only people with substantial cerebral artery obstruction may do well from MT. This includes the distal carotid artery and the proximal middle cerebral artery (segment M1). The size of a blocked vessel and NIHSS (National Institute of Health Stroke Scale) score are directly connected. Both the 2018 and 2019 versions of the AHA/ASA (American Heart Association/American Stroke Association) Guidelines for the Early Management of Patients with Acute Ischemic Stroke contained the recommendations that cases with AIS-LVO get endovascular therapy when administered during the time frame of 0–6 h after onset (Grade IA evidence). It is questionable whether this group of patients can be managed without the need for intravenous tissue plasminogen activator at the onset. When functional independence [modified Rankin Scale (mRS) score 2] was present at long-term follow-up, the endovascular intervention was favored. Tenecteplase, which differs from alteplase in terms of genetic variation, has a greater half-life and a higher level of fibrin selectivity, enabling bolus infusion. Studies have also demonstrated its efficacy and safety, as well as its long-term cost-effectiveness.

Evaluation of Physicians' Compliance With Secondary Prevention Among Ischemic Stroke Patients: A Retrospective Study.

Stroke is a leading cause of disability and death worldwide. Globally, stroke affects 13.7 million individuals every year. Several studies have shown an increase in the rehospitalization rate among stroke patients caused by non-adherence to secondary prevention as recommended by the American Heart Association/American Stroke Association (AHA/ASA) guideline. The aim of this study was to evaluate physicians' compliance with secondary prevention of stroke upon patients' discharge. A retrospective chart review study was conducted at King Fahad Medical City. The primary outcome of this study was the number of patients discharged with the recommended medications for the secondary prevention of ischemic stroke (IS). The data were collected from the patient's medical record files and analyzed using the Statistical Package for the Social Sciences (SPSS). Of the 675 patients who were screened for eligibility, 507 were included and 168 were excluded. The mean age of the patients was 59.5 (± 15.6) years. Of the 507 patients, 181 (35.7%) had a history of previous stroke. Overall, 376 (74%) stroke patients were discharged with appropriate secondary prevention recommendation per AHA/ASA guideline. This study stresses the importance of compliance with the AHA/ASA guideline for secondary stroke prevention and highlights the role of pharmacists in the stroke unit in which it is necessary to ensure that all stroke patients are discharged with the recommended medications to reduce recurrent stroke.

Development and Evaluation of a Physiologically Based Pharmacokinetic Model of Labetalol in Healthy and Diseased Populations.

Labetalol is a drug that exhibits both alpha and beta-adrenergic receptor-blocking properties. The American Heart Association/American Stroke Association (AHA/ASA) has recommended labetalol as an initial treatment option for the management of severe hypertension. The physiologically based pharmacokinetic (PBPK) model is an in silico approach to determining the pharmacokinetics (PK) of a drug by incorporating blood flow and tissue composition of the organs. This study was conducted to evaluate the primary reasons for the difference in PK after intravenous (IV) and oral administration in healthy and diseased (renal and hepatic) populations. A comprehensive literature search was done using two databases, PubMed and Google Scholar. Various PK parameters were screened for the development of the PBPK model utilizing a population-based PK-Sim simulator. Simulations were performed after creating building blocks firstly in healthy individuals and then in diseased patients after IV and oral administration. The disposition of labetalol after IV and oral administration occurring in patients with the hepatic and renal disease was predicted. The model was evaluated by calculating the Robs/pred ratio and average fold error (AFE), which was in the two-fold error range. Moreover, Box-whisker plots were made to compare the overall concentration of the drug in the body at various stages of disease severity. The presented model provides useful quantitative estimates of drug dosing in patients fighting against severe chronic diseases.

A Nursing Approach to Improving Critical Care Compliance With Vital Signs and Neurological Assessments in Post-IV-Alteplase Stroke Patients

Ischemic stroke represents 87% of all strokes. As global initiatives move forward with stroke care, health care providers and institutions will be called on to deliver the most current evidence-based care. The American Heart Association/American Stroke Association (AHA/ASA) estimates that 795 000 strokes occur each year; 610 000 are new strokes, and 185 000 are recurrent strokes. Eighty-seven percent are ischemic strokes; the overall mortality rate from stroke was 273 000, which makes stroke the fifth leading cause of death and the leading cause of disability in the United States. Stroke costs the United States an estimated $34 billion each year. This article outlines a nursing intervention regarding the use of intravenous thrombolytic therapy for treating acute ischemic stroke, the risk factors related to IV-alteplase, best-practice protocols, and the nursing role in efforts to deliver safe care. The conclusion reveals the need for health care organizations to explore opportunities, continually inspire innovation at the bedside, highlight nursing's essential contribution to acute stroke care, and encourage publishing improvements in patient care and the nurse practice environment.

Challenging the diagnosis and treatment of central retinal artery occlusion (CRAO) in emergency department

Central retinal artery occlusion (CRAO) is an occlusion of the central retinal artery that causes a disruption of blood flow to the retina and may result in retinal ischemia. According to the American Heart Association/American Stroke Association (AHA/ASA), CRAO is a type of acute ischemic stroke. There is some variation in CRAO management. Determining the most effective therapy remains challenging. We report a male, 58th-years-old, with sudden vision loss in the right eye for 4 hours of onset upon arrival at the Emergency Department. Patient aware, with hypertensive crisis, the right eye visual acuity was 1/300. Brain Magnetic Resonance Imaging (MRI) revealed multiple small vessel ischemic in the cortical-subcortical area. The patient was hospitalized and received ocular massage, antiplatelet, antihypertensive, and lipid-lowering therapy. Visual acuity in the right eye was minimally improved at discharge. CRAO is a form of stroke in the retina and may occur concurrently or progress into cerebral ischemia. Treatment with intravenous thrombolysis may be effective within 4.5 hours of onset. Ensuring the patient arrives at the emergency department and confirming the diagnosis of CRAO in this narrow time is still challenging.

Hematoma Evacuation Outcome in Patients with Spontaneous Supratentorial Intracerebral Hemorrhage

The mortality rate of spontaneous supratentorial intracerebral hemorrhage evacuation is still high and varies in all neurosurgical centers. Currently, minimally invasive surgery to evacuate bleeding has become an option, but not all neurosurgical centers can perform the procedures due to limited resources. In addition, there are several guidelines for determining which patients will undergo a surgery. This study assessed the outcome of selected patients who were operated on using micro neurosurgical procedures or external ventricular drainage for intraventricular hemorrhage between 2016 and 2021. Patients included in this study were recruited from a hospital in Jakarta, Indonesia and selected based on the guideline of the 2015 American Heart Association/American Stroke Association (AHA/ASA). The outcome was assessed by a modified Rankin scale (mRS). There were 301 patients with hemorrhagic stroke but only fifty patients were matched the criteria in the guideline. Male patients constituted the majority of the patients (n=28, 56%) and hypertension has occurred in 37 (74%) patients. The hematoma was mostly located in the intracerebral with intraventricular extension (n=27, 54%) patients. The pre-operative Glasgow Coma Scale (GCS) of 23 (46%) patients were comatose and the other was 9–13. Postoperatively, there were 37 (74%) patients with a scale of 13–15, but 10 (20%) patients died. Pair t-test of the preoperative and postoperative scales showed a significant difference, p &lt; 0.01. The outcome of 40 (80%) patients was good (modified Rankin scale of 0–3), and the Spearman’s rank correlation coefficient was -0.739 with the Sig.2-tailed was &lt;0.01. The outcome of spontaneous supratentorial intracerebral hemorrhage evacuation is good when selecting patients following the 2015 AHA/ASA guideline and there is a strong correlation between postoperative GCS with 3-month mRS results.

Analysis of Prescriptions for Dual Antiplatelet Therapy After Acute Ischemic Stroke

After the publication of the CHANCE (Clopidogrel in High Risk Patients With Acute Nondisabling Cerebrovascular Events) and POINT (Platelet-Oriented Inhibition in New Transient Ischemic Attack and Minor Ischemic Stroke) clinical trials, the American Heart Association/American Stroke Association (AHA/ASA) issued a new class 1, level of evidence A, recommendation for dual antiplatelet therapy (DAPT; aspirin plus clopidogrel) for secondary prevention in patients with minor ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤3). The extent to which variations in DAPT prescribing patterns remain and the extent to which practice patterns in the US are consistent with evidence-based guidelines are unknown. To evaluate the discharge DAPT prescribing patterns after publication of the new AHA/ASA guidelines and assess the extent of hospital-level variation in the use of DAPT for secondary prevention in patients with minor stroke (NIHSS score ≤3), as indicated by guidelines, and in patients with nonminor stroke (NIHSS score >3), for whom the risks and benefits of DAPT have not been fully established. This multicenter retrospective cohort study involved 132 817 patients from 1890 hospitals participating in the AHA/ASA Get With The Guidelines-Stroke program. Patients who were hospitalized for acute ischemic stroke and prescribed antiplatelet therapy at discharge between October 1, 2019, and June 30, 2020, were included. Minor ischemic stroke (NIHSS score ≤3) vs nonminor ischemic stroke (NIHSS score >3). The primary outcome was DAPT prescription at discharge. The extent to which variations in DAPT use were explained at the hospital level was assessed by calculating the median odds ratio (OR), which was derived using multivariable logistic regression analysis and compared the likelihood that 2 patients with identical clinical features admitted to 2 randomly selected hospitals (1 with higher propensity and 1 with lower propensity for DAPT use) would receive DAPT at discharge. Associations between hospital-level DAPT use among patients with minor vs nonminor stroke were evaluated using Pearson ρ correlation coefficients. Among 132 817 patients (median [IQR] age, 68 [59-78] years; 68 768 men [51.8%]), 4282 (3.2%) were Asian, 11 254 (8.5%) were Hispanic, 27 221 (20.5%) were non-Hispanic Black, 84 468 (63.6%) were non-Hispanic White, and 5592 (4.2%) were of other races and/or ethnicities (including American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and unable to determine). Overall, 86 551 patients (65.2%) presented with minor ischemic stroke, and 46 266 patients (34.8%) presented with nonminor ischemic stroke. After the 2019 AHA/ASA guideline updates, 40 661 patients (47.0%) with minor stroke (NIHSS median [IQR] score, 1 [0-2]) and 19 703 patients (42.6%) with nonminor stroke (NIHSS median [IQR] score, 6 [5-9]) received DAPT at discharge. Despite guideline recommendations, 45 890 patients (53.0%) with minor stroke did not receive DAPT. After accounting for patient characteristics, substantial hospital-level variations were found in the use of DAPT in those with minor stroke (median [IQR] hospital-level DAPT prescription rate, 44.8% [33.7%-57.7%]; range, 0%-91.7%; median OR, 2.03 [95% CI, 1.97-2.09]) when comparing 2 patients with identical risk factors discharged from 2 randomly selected hospitals, 1 with higher propensity and 1 with lower propensity for DAPT use. The use of DAPT in patients with nonminor stroke also varied significantly (median [IQR] hospital-level DAPT prescription rate, 41.4% [30.0%-53.8%]; range, 0%-100%; median OR, 1.90 [95% CI, 1.83-1.97]). Overall, hospitals that were more likely to prescribe DAPT for minor strokes were also more likely to prescribe DAPT for nonminor strokes (Pearson ρ = 0.72; P < .001). This cohort study found that despite updated AHA/ASA guidelines, more than 50% of patients with minor acute ischemic stroke did not receive DAPT at discharge. In contrast, more than 40% of patients with nonminor stroke received DAPT despite lack of evidence in this setting. These findings suggest that enhancing adherence to evidence-based DAPT practice guidelines may be a target for quality improvement in the treatment of patients with ischemic stroke.

Safety and efficacy of intravenous thrombolysis in acute ischemic stroke patients with a history of intracranial hemorrhage: A systematic review and meta-analysis

Acute ischemic stroke (AIS) is a fatal and debilitating condition killing 2.7 million people each year worldwide. The most commonly used treatment modality for AIS is intravenous thrombolysis (IVT) with alteplase which is indicated for those presenting within 4.5 h of onset. Due to a lack of reliable evidence on harm or benefit, the 2019 American Heart Association/American Stroke Association (AHA/ASA) guidelines consider a history of previous intracranial hemorrhage (ICH) as potentially harmful and no longer an absolute contraindication for IVT in patients with AIS, and the U.S. Food and Drug Administration (FDA) removed chronic ICH as a specific contraindication for IVT from the label in 2015. Despite a shift in guidelines, physicians frequently face the dilemmatic choice whether to administer IVT in this subset of patients due to the risk of symptomatic intracranial hemorrhage (SICH). The benefit of IVT in such patients has not been thoroughly investigated, and there are only a few studies on the subject in the literature to date. We conducted the present meta-analysis in an aim to provide solid evidence on the efficacy and safety of IVT for treating AIS in patients with a history of remote ICH. Our meta-analysis found that IVT improves functional outcomes in AIS patients with prior remote ICH without increasing SICH or all-cause mortality. These findings may contribute to the decision-making process for IVT administration in AIS patients.

Machine Learning Techniques in Blood Pressure Management During the Acute Phase of Ischemic Stroke.

Background and PurposeElevated blood pressure (BP) in acute ischemic stroke is common. A raised BP is related to mortality and disability, yet excessive BP lowering can be detrimental. The optimal BP management in acute ischemic stroke remains insufficient and relies on expert consensus statements. Permissive hypertension is recommended during the first 24-h after stroke onset, yet there is ongoing uncertainty regarding the most appropriate blood BP management in the acute phase of ischemic stroke. This study aims to develop a decision support tool for improving the management of extremely high BP during the first 24 h after acute ischemic stroke by using machine learning (ML) tools.MethodsThis diagnostic accuracy study used retrospective data from MIMIC-III and eICU databases. Decision trees were constructed by a hierarchical binary recursive partitioning algorithm to predict the BP-lowering of 10–30% off the maximal value when antihypertensive treatment was given in patients with an extremely high BP (above 220/110 or 180/105 mmHg for patients receiving thrombolysis), according to the American Heart Association/American Stroke Association (AHA/ASA), the European Society of Cardiology, and the European Society of Hypertension (ESC/ESH) guidelines. Regression trees were used to predict the time-weighted average BP. Implementation of synthetic minority oversampling technique was used to balance the dataset according to different antihypertensive treatments. The model performance of the decision tree was compared to the performance of neural networks, random forest, and logistic regression models.ResultsIn total, 7,265 acute ischemic stroke patients were identified. Diastolic BP (DBP) is the main variable for predicting BP reduction in the first 24 h after a stroke. For patients receiving thrombolysis with DBP <120 mmHg, Labetalol and Amlodipine are effective treatments. Above DBP of 120 mmHg, Amlodipine, Lisinopril, and Nicardipine are the most effective treatments. However, successful treatment depends on avoiding hyponatremia and on kidney functions.ConclusionThis is the first study to address BP management in the acute phase of ischemic stroke using ML techniques. The results indicate that the treatment choice should be adjusted to different clinical and BP parameters, thus, providing a better decision-making approach.

Everyday Abilities Scale for India in Screening for Poststroke Dementia Among Young Stroke Survivors.

Cognitive dysfunction after stroke is an important concern. We explored the utility of everyday abilities scale for India (EASI) for screening for dementia among young stroke survivors. We interviewed 150 young stroke survivors and caregivers. Vascular dementia was diagnosed according to American Heart Association-American Stroke Association (ASA-AHA) criteria. EASI was administered to all caregivers. Receiver operating characteristic curve analysis was used to determine the area under the curve and optimum cut-points for EASI for the identification of dementia. Median EASI scores among subjects with dementia (n=35; 23.3%) was 2 (interquartile range: 0-4) and significantly different from those without (median: 0; interquartile range: 0-1; P<0.001). The area under the curve was 0.768 (95% confidence interval: 0.674-0.863), and at the optimum cut-point of 2 on EASI, a sensitivity of 60% and specificity of 91.3% was achieved for the identification of dementia. EASI appears to be a promising tool to screen for dementia among young stroke survivors.

Endovascular treatment results in patients with large cerebral artery occlusions in a metropolis. Moscow Stroke Registry data over 2019

Objective: to assess results from the Stroke Network created on the basis of the Infarction Network in the metropolis Moscow for endovascular treatment in patients with occlusion of the large cerebral artery (the internal carotid artery, the M1 and M2 segments of the middle cerebral artery, and the main artery).Patients and methods. A total of 742 thromboextractions were performed in patients with ischemic stroke in Moscow Stroke Network hospitals in 2019. The final analysis included 729 patients aged 25 to 97 years (mean age, 71 years); of them there were 370 (50.8%) men and 359 (49.2%) women. The selection criteria for endovascular treatment for ischemic stroke were consistent with those set out in the 2015 American Heart Association/American Stroke Association (AHA/ASA) guidelines, which included a pre-stroke modified Rankin Scale (MRS) score of 0–1; ≥18 years of age; a National Institutes of Health Stroke Scale (NIHSS) score of ≥6; and an Alberta Stroke Programme Early CT score (ASPECTS) ≥6. The angiographic results were assessed using the Thrombolysis in Cerebral Infarction (TICI) scale. The clinical outcomes were measured with the NIHSS and the MRS.Results and discussion. Successful recanalization (TICI 2b/3) was achieved in 547 (75%) patients. The predominant technique for thromboextraction was thromboaspiration that was used in 376 (51.6%) patients. Combined procedures (the co-use of an aspiration catheter and a stent retriever) were the second most commonly used – in 231 (31.7%) patients. By the end of the 20th day, good functional recovery (MSR 0–2 scores) was observed in 213 (29.2%) patients. The 20-day mortality rate was 31.8%.Conclusion. The successfully functioning Infarction Network in Moscow was used to create the Stroke Network for treatment in patients with ischemic stroke and large cerebral artery occlusion, the clinical results of which are comparable to large European registry studies.

Adherence to American Heart Association/American Stroke Association Clinical Performance Measures in a Peruvian Neurological Reference Institute

BackgroundLittle is known about adherence to American Heart Association/American Stroke Association (AHA/ASA) stroke performance measures in developing countries like Peru. AimsWe assessed adherence and determined factors associated with adherence to the AHA/ASA stroke performance measures at a reference center for neurological diseases in Lima, Peru. MethodsWe conducted a retrospective chart review of 150 stroke patients admitted to the Neurological Institute of Neurological Science from 2014 to 2016 to ascertain adherence to 15 different AHA/ASA stroke performance measures. Adherence was measured as a simple proportion, with both single and composite measures. Associations were analyzed with nonparametric statistics and multivariate logistic regression. ResultsMean adherence to AHA/ASA stroke performance measures was 47%. We observed a statistically significant relationship between adherence to ischemic stroke performance measures and being married (OR = 3.78, 95% CI: 1.05–13.55), as well as an inverse relationship with an onset of symptoms of greater than 4.5 h prior to arrival at the hospital compared to those with ≤ 4.5 h (OR = 0.14, 95% CI: 0.02–0.97). Compared to patients with a lower National Institutes of Health Stroke Scale (NIHSS) score (<13), those with a score of ≥13 were less likely to have good adherence (OR = 0.11, 95% CI: 0.04–0.31). ConclusionsThe mean composite measure of adherence to internationally recognized standards of stroke management in our Peruvian institution was below the level needed for an achievement award by AHA/ASA. An intervention targeted toward stroke prevention and training could lead to improved outcomes of stroke patients in Peru.

Management of Acute Ischemic Stroke-Specific Focus on Anesthetic Management for Mechanical Thrombectomy.

Acute ischemic stroke is a neurological emergency with a high likelihood of morbidity, mortality, and long-term disability. Modern stroke care involves multidisciplinary management by neurologists, radiologists, neurosurgeons, and anesthesiologists. Current American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend thrombolytic therapy with intravenous (IV) alteplase within the first 3-4.5 hours of initial stroke symptoms and endovascular mechanical thrombectomy within the first 16-24 hours depending on specific inclusion criteria. The anesthesia and critical care provider may become involved for airway management due to worsening neurologic status or to enable computerized tomography (CT) or magnetic resonance imaging (MRI) scanning, to facilitate mechanical thrombectomy, or to manage critical care of stroke patients. Existing data are unclear whether the mechanical thrombectomy procedure is best performed under general anesthesia or sedation. Retrospective cohort trials favor sedation over general anesthesia, but recent randomized controlled trials (RCT) neither suggest superiority nor inferiority of sedation over general anesthesia. Regardless of anesthesia type, a critical element of intraprocedural stroke care is tight blood pressure management. At different phases of stroke care, different blood pressure targets are recommended. This narrative review will focus on the anesthesia and critical care providers' roles in the management of both perioperative stroke and acute ischemic stroke with a focus on anesthetic management for mechanical thrombectomy.

Blood Pressure Management Following Large Vessel Occlusion Strokes: A Narrative Review

Stroke is one of the leading causes of morbidity and mortality worldwide. Intravenous tissue plasminogen activator and mechanical thrombectomy comprise the two major treatments for acute ischemic stroke. Tissue plasminogen activator has been used for more than two decades and guidelines for hemodynamic management following tissue plasminogen activator administration are well established. However, mechanical thrombectomy is a relatively newer therapy and there is a paucity of evidence regarding hemodynamic management following large vessel occlusion strokes. The important tenets guiding the pathophysiology of large vessel occlusion strokes include understanding of cerebral autoregulation, collateral circulation, and blood pressure variability. In this narrative review, we discuss the current American Heart Association-American Stroke Association guidelines for the early management of acute ischemic stroke during different phases of the illness, encountered at different sections of a hospital including the emergency room, the neuro-interventional suite, and the intensive care unit. There is emerging evidence with regard to post-recanalization blood pressure management following large vessel occlusion strokes. Future research directions will include real-time blood pressure variability assessments, identifying the extent of impaired autoregulation, and providing guidelines related to range and personalized blood pressure trajectories for patients following large vessel occlusion strokes.

Endovascular Therapy for Patients With Acute Ischemic Stroke During the COVID-19 Pandemic: A Proposed Algorithm.

Endovascular Therapy for Patients With Acute Ischemic Stroke During the COVID-19 Pandemic: A Proposed Algorithm.