Adult Ischemic Stroke Research Articles

Abstract WP385: Delirium Significantly Contributes to Longer Hospitalization and Higher Post-Discharge Costs for Stroke Patients: An Analysis of Nationwide Data

Background: Healthcare costs related to delirium in the elderly and in the post-operative patient populations exceed $150 billion a year. Stroke patients are at a higher risk of developing delirium, which can significantly increase their healthcare costs. Incremental hospitalization and post-discharge costs associated with delirium have not been described in stroke patients. Methods: We analyzed Nationwide Readmission Data from 2010 - 2015 and identified adult (≥18) ischemic and hemorrhagic stroke patients. In-hospital delirium was identified using a validated algorithm. Patients who died during index hospitalization were excluded. Costs for index hospitalization and readmissions were determined using cost to charge ratios, and inflation adjusted to 2015 USD. We used generalized linear models to compare costs between delirious and non-delirious patients adjusting for demographics, comorbidities, illness severity, treatment intensity, in-hospital complications, and surgical procedures. Results: A total of 2,853,175 stroke discharges were included among whom 7.1% were documented to havein-hospital delirium on index admission. Delirious patients had a longer mean length of stay (12.01 vs 7.38 days), and higher 30-day readmission rates (16.7% vs 12.2%). At index admission, delirious patients had 9.9% higher adjusted costs of hospitalization as compared to non-delirious patients. For all admissions (including readmissions), delirious stroke patients had 12.3% higher adjusted costs of hospitalization, which translates into an additional $10,544.2 (2015) per hospitalization. (Figure) Conclusion: Our analyses highlight the potential cost savings in stroke care associated with prevention, recognition, early mitigation and effective management of delirium. Even though delirium prevalence may be underestimated in administrative data, these results indicate potential annual nationwide cost savings of more than $350 million for stroke care.

Abstract TP364: Developing a Pediatric Ischemic Stroke Code Protocol at a Comprehensive Stroke Center: The Georgetown Experience

Background/ Issue: Epidemiologically, pediatric strokes are rare; therefore, index of suspicion is low and many cases are not recognized early enough to qualify for acute treatment. With this small patient population, many regions have yet to develop protocols and policies for acute pediatric stroke response. In the District of Columbia, MedStar Georgetown University Hospital (MGUH) is the only Joint Commission Accredited Comprehensive Stroke Center with a pediatric intensive care unit. Purpose: The purpose of our program was to develop institutional protocols for pediatric stroke patients who are candidates for hyper-acute treatment. Protocols focused on pediatric patients who presented through our emergency department or were transferred from other facilities within the time window for acute treatment. The protocols were established to ensure a clear process for physicians and staff to follow. Methods: An interdisciplinary group met to discuss modification of our current Adult Ischemic Stroke Code Protocol needed for a coordinated approach to pediatric stroke patients. The team members included the Stroke Coordinator, Stroke Nurse Navigator, Stroke Nurse Practitioner, Pediatric Neurologist, Medical Director of the Pediatric ICU, Manager of the Pediatric ICU, Pediatric Anesthesia, Medical Director of the Stroke Program, and the Emergency Department Team. Results: The interdisciplinary team was able to adapt a protocol using the Adult Ischemic Stroke Code Protocol. Key differences between the adult and pediatric stroke code work-flow consisted of including pediatric neurologists early in the decision process, pediatric nurses to assist with monitoring children, and pediatric anesthesia for assistance with imaging and/or endovascular intervention. The order sets were adjusted to include weight- based calculations for medications, age-based monitoring parameters, and specific pediatric needs. Conclusion: It is possible to develop a Pediatric Stroke Code Protocol based on the Adult Ischemic Stroke Code Protocol to include all modifications appropriate for pediatric care and still maintain the rapid work-flow that everyone is familiar with. It is essential to include all key stakeholders to ensure a smooth and safe process.

Abstract WMP50: Age-Specific Female-Male Disparities in Endovascular Thrombectomy Use for Acute Ischemic Stroke in the United States

Introduction: Studies have suggested sex-related and age-related variations in frequency of reperfusion therapy, but have been limited by constrained geographic scope, data from before the modern thrombectomy era, and incomplete exploration of sex-related differences in discrete age ranges. We therefore analyzed sex-, age-, and sex-age interaction in the frequency of endovascular thrombectomy (EVT) for acute ischemic stroke in the US National Inpatient Sample. Methods: In the National Inpatient Sample , we identified all adult ischemic stroke EVT hospitalizations from 2010-2016, using ICD-9-CM and ICD-10-CM codes. Patient age was categorized as: <50y, 50-59y, 60-69y, 70-79y and ≥80ys. Rates of use of EVT were assessed standardized to the 2010 US Census population. Results: Among 50,573 EVT hospitalizations, 50.1% were female. The number of EVTs increased from 4091 in 2010 to 12,875 in 2016. Over the entire 7y time period, a sex-age interaction was noted: 49% in <50y; 37% in 50-59y; 35% in 60-69y; 53% in 70-79y; and 66% in ≥80y. This sex-age interaction was present as well for EVT rates per 100,000 individuals in the population, with the total ratio of female to male rate of EVT per 100,000: 0.93 for in <50y; 0.52 in 50-59y; 0.58 in 60-69y; 0.91 in 70-79y; and 1.1 in ≥80y. EVT utilization rates increased substantially over time in both men and women in all age groups. However, the ratio of women to men per 100,000 receiving EVT changed for only one age range, decreasing among <50y from 0.98 in 2010 to 0.79 in 2016 (P<0.05). Conclusion: While half of all endovascular thrombectomies in the US are performed in women, there are major age-related sex-specific variations in EVT rates, with rates of EVT much lower among women than men in 50-70 age group. Determinants of these age-specific female-male disparities in EVT treatment merit detailed investigation. Figure: Age- and sex-specific female to male thrombectomy utilization rates.

Causes, Risk Factors, and Clinical Outcomes of Stroke in Korean Young Adults: Systemic Lupus Erythematosus is Associated with Unfavorable Outcomes

Background and PurposeThe incidence of ischemic stroke (IS) in young adults is increasing, and the associated large socioeconomic impact makes understanding IS in young adults important. We investigated the causes of and risk factors for IS in young adults, and their impact on outcomes.MethodsThe Stroke in Korean Young Adults (SKY) study is a standardized multicenter prospective study involving eight medical centers of the Republic of Korea. First-ever IS patients aged 18 years to 44 years were prospectively included in this study within 7 days of stroke onset. Their outcomes at 3 months were analyzed.ResultsThis study enrolled 270 patients from April 2014 to December 2018, most (67.8%) of whom were male. About 41.5% of the patients had one or more vascular risk factors from among hypertension, diabetes mellitus, and dyslipidemia. However, only half of them had received regular treatment. Arterial dissection was more common in males, and systemic lupus erythematosus (SLE) and Moyamoya disease were more common in females. The outcome was favorable (modified Rankin Scale score of 0 or 1) in 81.9% of the patients at 3 months after stroke onset. More severe initial symptoms, higher initial glucose level, and SLE as a comorbidity were associated with unfavorable outcomes.ConclusionsYoung adult IS patients in Korea exhibit low awareness and poor management of their risk factors. Although the short-term outcome was relatively favorable in those patients, having SLE was associated with unfavorable outcomes. More attention needs to be paid for improving awareness and controlling risk factors in this population.

Sex disparity in long-term stroke recurrence and mortality in a rural population in the United States.

Background:Several studies suggest women may be disproportionately affected by poorer stroke outcomes than men. This study aims to investigate whether women have a higher risk of all-cause mortality and recurrence after an ischemic stroke than men in a rural population in central Pennsylvania, United States.Methods:We analyzed consecutive ischemic stroke patients captured in the Geisinger NeuroScience Ischemic Stroke research database from 2004 to 2019. Kaplan–Meier (KM) estimator curves stratified by gender and age were used to plot survival probabilities and Cox Proportional Hazards Ratios were used to analyze outcomes of all-cause mortality and the composite outcome of ischemic stroke recurrence or death. Fine–Gray Competing Risk models were used for the outcome of recurrent ischemic stroke, with death as the competing risk. Two models were generated; Model 1 was adjusted by data-driven associated health factors, and Model 2 was adjusted by traditional vascular risk factors.Results:Among 8900 adult ischemic stroke patients [median age of 71.6 (interquartile range: 61.1–81.2) years and 48% women], women had a higher crude all-cause mortality. The KM curves demonstrated a 63.3% survival in women compared with a 65.7% survival in men (p = 0.003) at 5 years; however, the survival difference was not present after controlling for covariates, including age, atrial fibrillation or flutter, myocardial infarction, diabetes mellitus, dyslipidemia, heart failure, chronic lung diseases, rheumatic disease, chronic kidney disease, neoplasm, peripheral vascular disease, past ischemic stroke, past hemorrhagic stroke, and depression. There was no adjusted or unadjusted sex difference in terms of recurrent ischemic stroke or composite outcome.Conclusion:Sex was not an independent risk factor for all-cause mortality and ischemic stroke recurrence in the rural population in central Pennsylvania.

Fibrinogen Concentrate for the Treatment of Thrombolysis-Associated Hemorrhage in Adult Ischemic Stroke Patients.

In patients with ischemic stroke who receive systemic recombinant tissue plasminogen activator (rt-PA), the risk of secondary hemorrhage is 1-7%. Fibrinogen supplementation with cryoprecipitate is recommended in patients with rt-PA-associated symptomatic hemorrhage. We examined whether fibrinogen concentrate can be used safely in this setting. A single-center retrospective case series was performed in patients who received fibrinogen concentrate for post-rt-PA hemorrhage between January-2012 and December-2017. The primary outcome was the incidence of in-hospital thromboembolic events and infusion reactions. Secondary outcomes included incidence of clinically significant ICH expansion within 24-hours and patient serum fibrinogen response to fibrinogen concentrate therapy. Thromboembolic events occurred in 3 (12.5%) of 24 patients included in the analysis. No patients experienced infusion-related reactions. Five of 22 patients with ICH experienced clinically significant hemorrhage expansion. Hypofibrinogenemia was corrected in 87.5%(7/8) of patients with baseline hypofibrinogenemia, with a median increase in serum fibrinogen 166 mg/dL. Median fibrinogen increase in patients without baseline hypofibrinogenemia was 18 mg/dL. Fibrinogen concentrate is a safe potential therapeutic option to restore fibrinogen levels in acute ischemic stroke patients with thrombolysis-associated hemorrhage.

Survival Time of Adult Ischemic Stroke Patients and Associated Risk Factors: A Retrospective Cohort Study at Felege Hiwot Referral Hospital

Survival Time of Adult Ischemic Stroke Patients and Associated Risk Factors: A Retrospective Cohort Study at Felege Hiwot Referral Hospital

Ischemic stroke segmentation in multi-sequence MRI by symmetry determined superpixel based hierarchical clustering

Automated estimation of ischemic stroke evolution across different brain anatomical regions has immense potential to revolutionize stroke treatment. Multi-sequence Magnetic Resonance Imaging (MRI) techniques provide information to characterize abnormal tissues based on their anatomy and physical properties. Asymmetry of the right and left hemispheres of the brain is an important cue for abnormality estimation but using it alone is susceptible to occasional error due to self-asymmetry of the brain. A precise estimate of the symmetry axis is therefore essential for accurate asymmetry identification, which holds the key to the proposed method. The proposed symmetry determined superpixel based hierarchical clustering (SSHC) method initially estimates the lesion from inter-hemispheric asymmetry. This asymmetry further determines the thresholding parameter for hierarchically clustering the superpixels leading to an automated and accurate lesion delineation. A multi-sequence MRI based pipeline also combines the estimations from individual sequences. SSHC is evaluated on different sequences of the Loma Linda University (LLU) dataset with 26 patients and the Ischemic Stroke Lesion Segmentation (ISLES′15) dataset with 28 patients. SSHC eliminates the need for manual determination of threshold for combining the superpixel clusters and is more reliable as it derives the information from the quick estimation of asymmetry. SSHC outperforms the state-of-the-art resulting in a high Dice similarity score of 0.704±0.27 and a recall of 0.85±0.01 which are 6% and 35% respectively higher than the challenge winning method. SSHC thus demonstrates a promising potential in the automated detection of (sub-)acute adult ischemic stroke.

Causes and Secondary Prevention of Acute Ischemic Stroke in Adults.

Stroke still remains a major cause of death and disability worldwide. Ischemic stroke is the most common type of stroke. Causes of ischemic stroke can be classified into large-artery atherosclerosis, cardiogenic embolism, small-vessel disease, stroke of other determined etiology, and stroke of undetermined etiology. Stroke causes in adults are mainly attributable to classical cardiovascular risk factors such as hypertension, diabetes, hypercholesterolemia, and smoking. In neuroimaging, stroke subtypes can be defined according to lesion localization and distribution (territorial infarct, lacunar infarct, hemodynamic infarct), which provide information as to the underlying etiology. Acute stroke management comprises rapid neurological assessment and rapid imaging to initiate effective reperfusion treatment with intravenous thrombolysis and mechanical thrombectomy. Stroke survivors are at increased risk of recurrent stroke. Therefore, diagnosis of the underlying cause and optimal secondary prevention is of importance. Pharmacologic secondary prevention includes antithrombotic therapy with antiplatelet drugs, oral anticoagulation, and treatment of vascular risk factors. Nonpharmacologic measures of secondary prevention comprise surgical or interventional revascularization of symptomatic carotid stenosis and interventional closure of patent foramen ovale.

Self- or caregiver-delivered manual remote ischemic conditioning therapy in acute ischemic stroke is feasible: the Early Remote Ischemic Conditioning in Stroke (ERICS) trial

Background: Infarct growth and recurrent stroke may be responsible for early morbidity and mortality in patients with acute ischemic stroke. Remote ischemic conditioning (RIC) may reduce infarct growth and prevent recurrent stroke; however, the exact dose remains to be investigated. We hypothesized that self- or caregiver-delivered six cycles of RIC intervention in acute ischaemic stroke for the first 12 weeks is feasible and safe compared to the four cycles RIC intervention. Methods: Adult ischemic stroke patients presenting within the first 48 h of symptom onset were screened. Patients with magnetic resonance imaging (MRI) evidence of acute infarct were randomized (1:1) to receive either four or six cycles of RIC therapy sessions two times daily in both arms for 12 weeks. All patients underwent MRI for infarct volume assessment and endothelial-dependent flow-mediated dilation (EDFMD) testing at baseline, 7 days and 12 weeks. Results: A total of 57 patients with mean±SD age of 59.4±12.4 years and median National Institute of Stroke Scale, 4 (IQR, 3-7) were randomised at a median of 23 h 30 min (IQR, 10 h 20 min to 30 h) after symptom onset to either the four-cycle (n=27) or six-cycle group (n=30). A total of 18 (66%) patients completed ≥50% sessions in 12 weeks in the four-cycles group; 21 (69.7%) patients completed ≥50% sessions in 12 weeks in the six-cycle group (p=0.4). There was no between-group differences in infarct growth, early neurological deterioration, recurrent stroke, and EDFMD at 7 days and 90 days. Conclusion: Both four and six cycles of short-term self- or caregiver-delivered RIC therapy is safe and may be feasible in acute ischaemic stroke patients. Randomised clinical trials are needed to assess efficacy to decrease infarct growth and prevent early neurological deterioration. Registration: Clinical Trial Registry - India: CTRI/2016/11/007495; registered on 25/11/2016.

Inherited Thrombophilia and the Risk of Arterial Ischemic Stroke: A Systematic Review and Meta-Analysis.

BackgroundInherited thrombophilias are well‐established predisposing factors for venous thromboembolism, but their role in arterial thrombosis, such as arterial ischemic stroke, remains uncertain. We aimed to evaluate the association between inherited thrombophilia (factor V Leiden, prothrombin G20210A mutation, protein C deficiency, protein S deficiency, and antithrombin deficiency) and risk of arterial ischemic stroke in adults.Methods and ResultsWe searched PubMed, EMBASE, and Cochrane Library Databases from inception to December 31, 2018. We included case‐control or cohort studies of adults reporting the prevalence of inherited thrombophilias in those with arterial ischemic stroke and subjects without arterial ischemic stroke. Two reviewers (T.C., E.D.) independently searched the literature and extracted data. Pooled odds ratios (ORs) and 95% CIs were calculated using random‐effects model. We identified 68 eligible studies, which collectively enrolled 11 916 stroke patients and 96 057 controls. The number of studies reporting factor V Leiden, prothrombin G20210A mutation, protein C deficiency, protein S deficiency, and antithrombin deficiency were 56, 45, 15, 17, and 12, respectively. Compared with controls, patients with arterial ischemic stroke were significantly more likely to have the following inherited thrombophilias: factor V Leiden (OR, 1.25; 95% CI, 1.08–1.44; I2=0%), prothrombin G20210A mutation (OR, 1.48; 95% CI, 1.22–1.80; I2=0%), protein C deficiency (OR, 2.13; 95% CI, 1.16–3.90; I2=0%), and protein S deficiency (OR, 2.26; 95% CI, 1.34–3.80; I2=8.8%). Statistical significance was not reached for antithrombin deficiency (OR, 1.25; 95% CI, 0.58–2.67; I2=8.8%).ConclusionsInherited thrombophilias (factor V Leiden, prothrombin G20210A mutation, protein C deficiency, and protein S deficiency) are associated with an increased risk of arterial ischemic stroke in adults. The implications of these findings with respect to clinical management of patients with ischemic stroke require further investigation.

Ischemic Stroke in Adults With Congenital Heart Disease: A Population-Based Cohort Study.

BackgroundCongenital heart disease (CHD) is associated with risk factors for ischemic stroke including cardiac arrhythmias and heart failure. However, few long‐term follow‐up data exist on ischemic stroke risk and associated mortality in adults with CHD.Methods and ResultsUsing Danish nationwide registries, we identified individuals aged ≥18 years diagnosed with CHD, at any age, from 1963 to 2017 and a sex and birth year‐matched (1:10) general population comparison cohort. We computed risks, as well as sex and birth year‐adjusted hazard ratios (aHRs) for ischemic stroke and 30‐day post‐stroke mortality in CHD adults compared with the general population. Analyses were stratified according to age <60 years (young) and ≥60 years (older). We identified 16 836 adults with CHD. The risk of ischemic stroke at age 60 years was 7.4% in the CHD cohort and 2.9% in the general population cohort. The adjusted hazard ratios for ischemic stroke compared with the general population was 3.8 (95% CI: 3.3–4.3) in young CHD adults and 1.6 (95% CI: 1.4–1.9) in older CHD adults. The adjusted hazard ratios for post‐stroke mortality compared with the general population was 2.3 (95% CI: 1.2–4.4) in young CHD adults and 1.3 (95% CI: 0.9–1.9) in older CHD adults.ConclusionsBoth younger and older CHD adults have an increased risk of ischemic stroke and by 60 years of age 7.4% of CHD adults will have had an ischemic stroke. Post‐stroke mortality was also increased in CHD adults compared with the general population.

PB2436 PLATELET GLYCOPROTEIN (GP IIB/IIIA) GENE POLYMORPHISM AS A RISK FACTOR FOR ISCHEMIC CEREBRO VASCULAR STROKE

Background:Recent data which indicate considerable variability in platelet phenotype which accounts for differences in platelet surface receptor function, count and reactivity with subsequent thrombotic events. The identification of a contribution by platelet glycoproteins polymorphism to Ischemic cerebrovascular stroke which is a multifactorial, polygenic pathological process is challenging.Aims:Assessment of the genetic platelet glycoprotein (GPIIb/IIIa) polymorphism, as a genetic risk factor in ischemic cerebrovascular stroke patients in Ismailia, Egypt.Methods:Study population included: Fifty adult ischemic cerebrovascular stroke patients (acute, recent or old) and fifty‐healthy control group matching the patients group. Hematological and biochemical; Molecular assessment included DNA extraction and purification using micro‐centrifugation technique were done. DNA amplification was carried out by PCR‐RFLP technique. Genotypic determination of the platelet GPIIb/IIIa genotypes was carried out using agarose gel electrophoresis of the PCR products after endonuclease restriction with enzyme Msp‐I.Results:Platelet glycoprotein GP IIIa (PlA2/A2) genotypic distribution showed a statistically significant difference in ischemic cerebrovascular stroke patients in comparison with the healthy matched controls (the control group: GPIIIa (PlA1/PlA1: homozygous) 82%, GPIIIa (PlA1/PlA2 heterozygous) 16%, GPIIIa (PlA1/PlA1), and GPIIIa (PlA2/PlA2 homozygous) 2%.While the patients group: GPIIIa (PlA1/PlA1: homozygous) 58%, GPIIIa (PlA1/PlA2 heterozygous) 32%, GPIIIa (PlA1/PlA1), and GPIIIa (PlA2/PlA2 homozygous) 10%. There were statistically significant differences in between study groups regarding Platelet GP IIIa (PlA2/A2)genotypes, smoking, hypertension, diabetes, and dyslipidaemia; dyslipidaemia showed the highest odds ratio of all the risk factors.Summary/Conclusion:Conclusions: In this population, the genetic platelet glycoprotein GPIIIa (PlA1/PlA2) polymorphism is a reliable and significant predictor biomarker in the prediction of ischemic cerebrovascular stroke and the platelet glycoprotein GPIIIa (PlA2/PlA2) mutant allele was identified as a risk factor ischemic cerebrovascular stroke.image

Abstract TP192: Trends in Hospital Admissions for Stroke Among Patients With Sickle Cell Disease

Introduction: Sickle cell disease (SCD) is a major risk factor for ischemic and hemorrhagic stroke. Approximately 10% of children with SCD will have a stroke, a rate that increases to nearly 25% by age 45. In adults with SCD, stroke management guidelines are limited and recent national trends in hospital admission and mortality are not known. We sought to describe the recent trends in national hospital admissions for ischemic stroke, associated mortality and other socio-demographic traits, among adult patients with SCD. Methods: The National Inpatient Sample (NIS) is a healthcare database that approximates a 20 percent stratified sample of all hospital discharges in the US. We queried the NIS from 2006-2014 using ICD-9 codes for a primary diagnosis of ischemic stroke and any secondary diagnosis of SCD. Our primary outcomes were hospital admission rates and mortality. We stratified admissions by presence of SCD and accounted for race (AA, Hispanic, NHW and other), sex, age, hospital characteristics, US region, household income, insurance type, disease severity and other factors using multivariable logistic regression. Results: We found a total of 1,052,442 observations for ischemic stroke from 2006-2014, of which 743 had a secondary diagnosis of SCD. Ischemic stroke and SCD accounted for 0.32% of all hospitalization in blacks, compared to 0.04 in whites and Hispanics each. Patients with both diagnoses were also much more likely to be younger, accounting for 0.57% of all admission in those 18-44 compared to only 0.02% in those older than 65. In the adjusted model, stroke admission rates among patients with SCD steadily declined from 2006-2008 compared to 2012-2014 (OR 0.82, CI 0.789-0.86). There was no difference in hospital mortality for patients with SCD compared to those without it (OR 1.2, CI 0.84-1.6). Having medicaid was associated with increased in mortality (OR 1.43, CI 1.37-1.51) and so was income, with the first quartile in income having the highest mortality OR 1.03, CI 1.01-1.05). Conclusion: Hospital admissions for ischemic stroke in adults with SCD have declined from 2006 to 2014. SCD remains an under-recognized stroke risk factor in young AA. Insurance type and income were associated with increased mortality.

Abstract WP366: Readmission for an Infection After a Stroke Admission: The Role of Hospital Acquired Infections

Background and Purpose: Stroke patients are at increased risk for acquiring infections in the hospital. This study aimed to examine whether an infection acquired during the initial stroke admission contributes to increased risk of readmission and infection during readmission. Methods: Electronic data were collected retrospectively for all adult ischemic stroke patients admitted to three New York City hospitals from 2006-2016. A validated computer algorithm defined infections based on laboratory culture data. Multivariable logistic regression was used to evaluate the crude and adjusted association of infections present on admission (IPOA) and healthcare-associated infections (HAI) with 60-day readmissions, and infection during readmission. Results: Among the 10436 stroke patients, 17% had infections during initial admission of which 52% were IPOA and 48% were HAI. The risk of readmission (Table) was significantly higher for those with HAIs (OR=1.20; 95% CI: 1.02-1.42) but not IPOA (OR=1.07; 95% CI: 0.91- 1.25) after adjusting for covariates. The presence of infection during the 60-day readmission was also independently predicted by HAI (OR=2.20; 95% CI: 1.79-2.71), and IPOA (OR=1.70; 95% CI: 1.32-2.17). Conclusion: Among stroke patients, HAI and IPOA were predictors of readmission within 60 days and infection during readmission. Patients who had an HAI or IPOA during their stroke stay were at increased risk to have an infection during their readmission hospitalization. The findings also indicate that the HAI-associated poor prognosis makes patients more susceptible to new infections during their readmission, or worsening of their current infection.

Ischemic stroke in young adults.

Although the clinical approach to the young adult stroke patient is similar to that of an older adult, several important differences exist. The purpose of this article is to concisely review the epidemiology, pathophysiology, risk factors, clinical manifestations, diagnostic methods and current treatment options for the young adult ischemic stroke patient. Evidence clearly indicates that the incidence ischemic stroke in young adults is on the rise. A variety of factors are implicated, including an increased burden of classic and emerging vascular risk factors, and improved stroke detection, among other causes. Improved awareness, prevention and successful treatment of the young adult stroke patient is of great importance, particularly given the major long-term socioeconomic impact strokes have on the patient, their family and society at large. In this review, we focus on the latest epidemiologic, diagnostic and treatment paradigms to improve physician awareness and optimize outcomes in young adult ischemic stroke patients. An overview of the clinical presentations of various stroke syndromes is described, emphasizing key causes physicians should consider, as well as providing recommendations regarding evaluation and treatment. Important causes including dissection and inflammatory and noninflammatory vasculopathies are emphasized. The diagnoses of cerebral venous thromboses, cardioembolic stroke and paradoxical emboli are also discussed. The effects of established and emerging risk factors on large and small vessel disease, as well as genetic contributions, are also highlighted.

Neuroprotective Effect of IRL-1620, an Endothelin B Receptor Agonist, on a Pediatric Rat Model of Middle Cerebral Artery Occlusion.

Objective: The purpose of this study was to determine the potential neuroprotective effect of endothelin B (ETB) receptor agonist IRL-1620 treatment in a pediatric model of ischemic stroke.Design: A prospective, animal model study.Setting: An experimental laboratory.Subjects: Three-month-old male Wistar Han rats.Interventions: The rats underwent permanent middle cerebral artery occlusion (MCAO). At 2, 4, and 6 h post MCAO, they were treated with saline, IRL-1620 (5 μg/kg, IV), and/or ETB antagonist BQ788 (1 mg/kg, IV).Measurements and Main Results: The rats were evaluated over the course of 7 days for neurological and motor deficit, cerebral blood flow (CBF), and infarct volume. Young rats treated with IRL-1620 following MCAO improved significantly in neurological and motor assessments as compared to the vehicle-treated group, as measured by neurological score (P = 0.00188), grip test (P < 0.0001), and foot-fault error (P = 0.0075). CBF in the infarcted hemisphere decreased by 45–50% in all groups immediately following MCAO. After 7 days, CBF in the infarcted hemisphere of the IRL-1620 group increased significantly (P = 0.0007) when compared to the vehicle-treated group (+2.3 ± 23.3 vs. −45.4 ± 10.2%). Additionally, infarct volume was significantly reduced in IRL-1620-treated rats as compared to vehicle-treated rats (P = 0.0035, 41.4 ± 35.4 vs. 115.4 ± 40.9 mm3). Treatment with BQ788 blocked the effects of IRL-1620.Conclusions: IRL-1620 significantly reduced neurological and motor deficit as well as infarct volume while increasing CBF in a pediatric rat model of cerebral ischemia. These results indicate that selective ETB receptor stimulation may provide a novel therapeutic strategy in the treatment of pediatric ischemic stroke as has been demonstrated in adult ischemic stroke.

Impact of risk factors for recurrence after the first ischemic stroke in adults: A systematic review and meta-analysis

Risk factors for first-ever stroke have been studied extensively, while those for recurrent stroke are not accurately understood. To provide the adequate secondary prevention for the patients, it is necessary to reveal the risk factors that dominate recurrent stroke. Multiple databases were adopted to search for the relevant studies and full-text articles involving in the risk factors for stroke recurrence were reviewed. Meta-analyses were performed with Review Manager 5.0 to estimate the impact of risk factors included, and forest plots, quality analysis and bias analysis for the articles included were also conducted. Finally 11 studies which eventually satisfied the eligibility criteria were included in this study, and patients with initial stroke and recurrent stroke were 14,455 and 1545, respectively. The meta-analyses showed that hypertension (OR = 1.67, 95%CI [1.45, 1.92], P < 0.00001), diabetes mellitus (OR = 1.50, 95%CI [1.30, 1.72], P < 0.00001), atrial fibrillation (OR = 1.88, 95%CI [1.56, 2.25], P < 0.00001) and coronary heart disease (OR = 1.77, 95%CI [1.31, 2.39], P = 0.0002) played a certain role in the process of stroke recurrence, while the influences of dyslipidemia (OR = 0.92, 95%CI [0.67, 1.27], P = 0.62) and smoking (OR = 0.96, 95%CI [0.80, 1.15], P = 0.62) were not significant. Hypertension, diabetes mellitus, atrial fibrillation and coronary heart disease of patients with stroke have statistical associations with recurrent stroke, and secondary prevention and treatment should be provided to curb the recurrence.

Childhood stature and growth in relation to first ischemic stroke or intracerebral hemorrhage

Background and Purpose— Attained height, an indicator of genetic potential and childhood growth environment, is inversely associated with stroke, but the mechanisms are poorly understood. We investigated whether childhood height and growth are associated with ischemic stroke (IS) and intracerebral hemorrhage (ICH). Methods— In a cohort of Danish schoolchildren born 1930 to 1989, with measured height from 7 to 13 years, we investigated associations of childhood stature and growth with risks of adult IS and ICH. Cox proportional hazards regressions were performed to estimate hazard ratios (HRs) with CIs separately for women and men. Results— Among 311 009 individuals, 10 412 were diagnosed with IS and 2546 with ICH. Height at 7 years was inversely and significantly associated with IS in both sexes (per z score, equivalent to ≈5.2 cm in women and 5.1 cm in men; women: HR=0.89 [95% CI: 0.87–0.92]; men: HR=0.90 [95% CI: 0.88–0.92]) and with ICH in men (HR=0.89 [95% CI: 0.84–0.94]) but not in women (HR=0.97 [95% CI: 0.91–1.04]). Associations were similar at older childhood ages and were stable throughout the study period. No statistically significant associations for growth from 7 to 13 years were observed for IS or ICH. Conclusions— Short stature at 7 to 13 years is significantly associated with increased risks of IS in both sexes and with ICH in men. Growth during this period of childhood is not significantly associated with either of these stroke subtypes, suggesting that underlying mechanisms linking height with risks of stroke may exert their influence already by early childhood.

A Pediatric and Neonatal Critical Care Transport Team's Standard of Care for Suspected Stroke of a Pediatric Patient

Background A 314 bed free standing Children's Hospital is the region's first and only dedicated pediatric stroke center offering comprehensive, individualized treatment protocols for children (Children's Mercy, 2018). The WHO estimates 1-2/210,000 children will have a stroke. Mortality is 2-11% but persistent neurological deficit will occur in 68-73% of children who experience a stroke (Bernard Ann Neurol 2008). Recognition and early intervention are critical to minimizing brain damage (Mutka Sharma, MD). Depending on the length of time since the stroke, treatment options can vary. Rapid identification and treatment can be lifesaving and/or potentially improve neurologic outcomes (Children's Mercy 2018). Objectives To provide a Pediatric and Neonatal Critical Care Transport team the training, job aides and standardization for the recognition and treatment of a pediatric patient with stroke symptoms requiring transport to a Pediatric Stroke Center. ●Identify pediatric patients with symptoms concerning for stroke ●Initiate a Stroke Alert Protocol if child has focal neurologic deficit and meets criteria for activation ●Aid in the pre Pediatric Stroke Center triage process and stroke evaluation ●Provide rapid assessment, stabilization, and transport of children with stroke-like symptoms to pediatric center ●Initiate neuroprotective measures designed to minimize secondary neurologic injury IMPLEMENTATION ●Clinical Practice Guideline ●Suspected Stroke Checklist ●tPA Administration and Monitoring Guidelines Results Because symptoms of a pediatric ischemic stroke can vary greatly from an adult ischemic stroke, our Critical Care Transport Team is specially trained and prepared to transport a pediatric patient with stroke symptoms from anywhere in the area. If a pediatric ischemic stroke is suspected by a referral and/or our transport team, our collaborative team of Medical Control Physicians (MCP), Transport Personnel, Referral Physicians and Emergency Room Physicians are all specially trained to activate our stroke protocol immediately should a patient present with stroke symptoms. Since implementation we have transported and treated 2 patients with basilar artery stroke. Both patients had successful clot retrieval and full neurological recovery! Several other critical diagnosis as a result of being a stroke mimicker were made during the stroke alert and/or stroke activation procedure including brain tumor, HSV encephalitis, brain abscess, Schawannoma and Moya Moya disease. Conclusion There has been an increase in rapid diagnosis, early recognition and treatment of pediatric patients with acute ischemic stroke and other stroke mimickers that required emergent intervention following implementation of our Stroke Alert Protocol, Clinical Practice Guideline, Suspected Stroke Checklist and tPA Administration and monitoring Guideline for Pediatric and Neonatal Critical Care Transport.