Management Of Acute Ischemic Stroke Research Articles

Current management of acute ischemic stroke in Africa: A review of the literature.

Acute ischemic stroke is one of the leading causes of disability and mortality globally, with increasing incidence in Africa, as the continent is already burdened with infectious diseases. Rapid diagnosis and efficient treatment are crucial, as even a slight delay in reperfusing the brain significantly affects the recovery outcome. Neuroimaging is vital for optimal care and thrombolytic or endovascular therapy in specialized stroke care units. This review aims to discuss the burden of acute ischemic stroke in Africa and how health care systems have tried to reduce the incidence and improve outcomes for the disease. Data were collected through the online databases PubMed, Ovid MEDLINE, ScienceDirect, and Embase. All articles related to acute ischemic stroke in Africa were considered. The medical care for acute ischemic stroke in Africa is far from optimal, with little adherence to recommended protocols. There is a lack of public awareness of the disease, imaging infrastructure, personnel, stroke care units, and recovery facilities due to poor funding. Poor knowledge of stroke signs and symptoms results in delay in treatment and poor prognosis. We urge African leaders and private entities to invest in stroke care by building appropriate infrastructures, providing medical equipment, and implementing guidelines and sustainable follow-up systems. Telehealth is a suggested strategy to mitigate the scarcity of health personnel, and international and national efforts to increase treatment affordability should be doubled. Further extensive research on the impact of acute ischemic stroke on the African population is encouraged.

Social inequalities and gender differences in healthcare management of acute ischaemic stroke in France.

There are regional disparities in access to stroke units in France. Several studies have shown that living in disadvantaged areas is associated with a higher frequency of stroke, worse severity at presentation, increased level of dependency and higher mortality rates. However, few studies have explored the association between an individual's socioeconomic characteristics and stroke care. Our study aimed to determine if living standards are associated with stroke unit access for patients admitted to hospital for acute ischaemic stroke. Using the EDP-Santé French administrative database, all patients admitted to hospital for acute ischaemic stroke between 2014 and 2017 were selected. Acute ischaemic stroke corresponded to hospital stay with International Classification of Diseases 10th Revision codes I63 or I64 as the main diagnosis. Multivariate logistic regression was used to identify if standard of living was associated with likelihood of admission to a stroke unit. In all, 14,123 acute care episodes were identified, corresponding to 335,273 episodes in the general population when appropriately weighted. Of these, 52.9% were admitted to a stroke unit. Being in the first (i.e., poorest) living standard quartile was associated with lower likelihood of admission to a stroke unit compared with the fourth (i.e., wealthiest) quartile, and was associated with a higher likelihood of paralysis and language disorder, and death at 1year. A low living standard was associated with lower likelihood of admission to a stroke unit as well as a greater chance of paralysis and aphasia at the end of hospitalization and a higher possibility of death at 1year after stroke. Greater access to stroke units for disadvantaged people should be promoted.

M1, M2: Time to Bid Adieu!

M1, M2: Time to Bid Adieu!

Transradial Versus Transfemoral Approach for Endovascular Thrombectomy of Left Anterior Circulation Stroke With Bovine Arch

Transradial Versus Transfemoral Approach for Endovascular Thrombectomy of Left Anterior Circulation Stroke With Bovine Arch

Toward a Better Understanding of Sex- and Gender-Related Differences in Endovascular Stroke Treatment: A Scientific Statement From the American Heart Association/American Stroke Association.

There are many unknowns when it comes to the role of sex in the pathophysiology and management of acute ischemic stroke. This is particularly true for endovascular treatment (EVT). It has only recently been established as standard of care; therefore, data are even more scarce and conflicting compared with other areas of acute stroke. Assessing the role of sex and gender as isolated variables is challenging because they are closely intertwined with each other, as well as with patients' cultural, ethnic, and social backgrounds. Nevertheless, a better understanding of sex- and gender-related differences in EVT is important to develop strategies that can ultimately improve individualized outcome for both men and women. Disregarding patient sex and gender and pursuing a one-size-fits-all strategy may lead to suboptimal or even harmful treatment practices. This scientific statement is meant to outline knowledge gaps and unmet needs for future research on the role of sex and gender in EVT for acute ischemic stroke. It also provides a pragmatic road map for researchers who aim to investigate sex- and gender-related differences in EVT and for clinicians who wish to improve clinical care of their patients undergoing EVT by accounting for sex- and gender-specific factors. Although most EVT studies, including those that form the basis of this scientific statement, report patient sex rather than gender, open questions on gender-specific EVT differences are also discussed.

Neuroprotection in Acute Ischemic Stroke: A Battle Against the Biology of Nature.

Stroke is the second most common cause of global death following coronary artery disease. Time is crucial in managing stroke to reduce the rapidly progressing insult of the ischemic penumbra and the serious neurologic deficits that might follow it. Strokes are mainly either hemorrhagic or ischemic, with ischemic being the most common of all types of strokes. Thrombolytic therapy with recombinant tissue plasminogen activator and endovascular thrombectomy are the main types of management of acute ischemic stroke (AIS). In addition, there is a vital need for neuroprotection in the setting of AIS. Neuroprotective agents are important to investigate as they may reduce mortality, lessen disability, and improve quality of life after AIS. In our review, we will discuss the main types of management and the different modalities of neuroprotection, their mechanisms of action, and evidence of their effectiveness after ischemic stroke.

Commentary on “Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional Physicians”

The article “Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional Physicians” addresses an important and controversial issue of whether nonneuroscience interventional physicians should be performing stroke thrombectomy ( 1 Sacks D. Dhand S. Hegg R. et al. Outcomes of stroke thrombectomy performed by interventional radiologists versus neurointerventional physicians. J Vasc Interv Radiol. 2022; 33: 619-626 Google Scholar ). There is convincing evidence that stroke thrombectomy improves the clinical outcomes of large vessel occlusion (LVO) anterior circulation strokes and that it is cost effective ( 2 Powers W.J. Rabinstein A.A. Ackerson T. et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019; 50: e344-e418 Crossref PubMed Scopus (1847) Google Scholar , 3 Bulwa Z. Chen M. Stroke center designations, neurointerventionalist demand, and the finances of stroke thrombectomy in the United States. Neurology. 2021; 97: S17-S24 Crossref PubMed Scopus (2) Google Scholar ). This article provides data to support the position that interventional radiology (IR) physicians with additional training can achieve technical and clinical outcomes similar to those obtained by neurointerventional (NI) physicians. We do not take sides in this controversy. The purposes of this commentary are to appraise the current article critically, to examine its potential implications, and to provide an update on the issues of the supply of, demand for, and access to stroke thrombectomy. Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional PhysiciansJournal of Vascular and Interventional RadiologyVol. 33Issue 6PreviewTo test the hypothesis that interventional radiologists (IRs) and neurointerventional (NI) physicians have similar outcomes of endovascular stroke thrombectomy (EVT), which could be used to improve the availability of thrombectomy. Full-Text PDF

Protected Code Stroke: Acute Ischemic Stroke Management during Coronavirus Disease 2019 Pandemic

Protected Code Stroke: Acute Ischemic Stroke Management during Coronavirus Disease 2019 Pandemic

Acute Pain: A Consideration in Blood Pressure Management in Acute Ischemic Stroke in the Sickle Cell Patient (P18-10.004)

Acute Pain: A Consideration in Blood Pressure Management in Acute Ischemic Stroke in the Sickle Cell Patient (P18-10.004)

Knowledge of acute stroke management and the predictors among Malaysian healthcare professionals.

BackgroundDespite rapid advances in acute ischaemic stroke (AIS) management, many healthcare professionals (HCPs) might not be aware of the latest recommended management of AIS patients. Therefore, we aimed to determine the level and factors associated with AIS management knowledge among Malaysian HCPs.MethodsThis cross-sectional online questionnaire study was conducted nationwide among 627 HCPs in Malaysia using the Acute Stroke Management Questionnaire (ASMaQ). Multiple logistic regression was used to predict the relationship between the independent variables (age, gender, years of service, profession, work setting, work sector, seeing stroke patients in daily practice, and working with specialists) and the outcome variable (good vs poor knowledge).ResultsApproximately 76% (95% CI [73–79%]) of HCPs had good overall knowledge of stroke. The highest proportion of HCPs with good knowledge was noted for General Stroke Knowledge (GSK) [88.5% (95% CI [86–91%])], followed by Advanced Stroke Management (ASM) [61.2% (95% CI [57–65%])] and Hyperacute Stroke Management (HSM) [58.1% (95% CI [54–62%])]. The odds of having poor knowledge of stroke were significantly higher among non-doctor HCPs [adjusted OR = 3.46 (95% CI [1.49–8.03]), P = 0.004]; among those not seeing stroke patients in daily practice [adjusted OR = 2.67 (95% CI [1.73–4.10]), P < 0.001]; and among those working without specialists [adjusted OR = 2.41 (95% CI [1.38–4.18]), P = 0.002].ConclusionsStroke education should be prioritised for HCPs with limited experience and guidance. All HCPs need to be up-to-date on the latest AIS management and be able to make a prompt referral to an appropriate facility. Therefore, more stroke patients will benefit from advanced stroke care.

Japan Stroke Society Guideline 2021 for the Treatment of Stroke.

The revised Japan Stroke Society Guidelines for the Treatment of Stroke were published in Japanese in July 2021. In this article, the extracted recommendation statements are published. The revision keeps pace with the great progress in stroke control based on the recently enacted Basic Act on Stroke and Cardiovascular Disease in Japan. The guideline covers the following areas: primary prevention, general acute management of stroke, ischemic stroke and transient ischemic attack, intracerebral hemorrhage, subarachnoid hemorrhage, asymptomatic cerebrovascular disease, other cerebrovascular disease, and rehabilitation.

Temperature Management in the ICU.

Temperature abnormalities are recognized as a marker of human disease, and the therapeutic value of temperature is an attractive treatment target. The objective of this synthetic review is to summarize and critically appraise evidence for active temperature management in critically ill patients. We searched MEDLINE for publications relevant to body temperature management (including targeted temperature management and antipyretic therapy) in cardiac arrest, acute ischemic and hemorrhagic stroke, traumatic brain injury, and sepsis. Bibliographies of included articles were also searched to identify additional relevant studies. English-language systematic reviews, meta-analyses, randomized trials, observational studies, and nonhuman data were reviewed, with a focus on the most recent randomized control trial evidence. Data regarding study methodology, patient population, temperature management strategy, and clinical outcomes were qualitatively assessed. Temperature management is common in critically ill patients, and multiple large trials have been conducted to elucidate temperature targets, management strategies, and timing. The strongest data concerning the use of therapeutic hypothermia exist in comatose survivors of cardiac arrest, and recent trials suggest that appropriate postarrest temperature targets between 33°C and 37.5°C are reasonable. Targeted temperature management in other critical illnesses, including acute stroke, traumatic brain injury, and sepsis, has not shown benefit in large clinical trials. Likewise, trials of pharmacologic antipyretic therapy have not demonstrated improved outcomes, although national guidelines do recommend treatment of fever in patients with stroke and traumatic brain injury based on observational evidence associating fever with worse outcomes. Body temperature management in critically ill patients remains an appealing therapy for several illnesses, and additional studies are needed to clarify management strategies and therapeutic pathways.

Effects of endovascular therapy for mild stroke due to proximal or M2 occlusions: meta-analysis

ObjectiveTo conduct a meta-analysis to evaluate the effect of endovascular therapy (EVT) in mild acute ischemic stroke (AIS) due to proximal versus distal occlusions.MethodsWe searched PubMed, Embase, the Cochrane Library,...

Review of net water uptake in the management of acute ischemic stroke.

CT densitometry-based methods to directly quantify net water uptake in ischemic brain tissue have been increasingly applied recently. There is potential for net water uptake to be used as an imaging biomarker for the pathophysiology of infarcted lesions. This review is aimed at summarizing the potential and current status of the application of net water uptake as a biomarker in the management of ischemic stroke and future directions in this context. Specifically, we provide a brief overview of the principle and different methods of net water uptake measurement, followed by a discussion of the role of net water uptake in predicting malignant brain edema and hemorrhagic transformation, evaluating lesion age, and predicting the efficacy of reperfusion therapy and long-term clinical prognosis. Artificial intelligence will help address the lack of automation and standardization in the measurement of net water absorption. Further validation of net water uptake in a prospective multicenter setting is necessary. KEY POINTS: • NWU can be used as a quantitative imaging biomarker for developing malignant brain edema in anterior and posterior circulation strokes. • The difference in NWU in edema arrest or reversibility suggests that rapid and successful revascularization can influence the progression of ischemic edema. • NWU can be used to predict the age of a lesion, with predictive power comparable to that of DWI/FLAIR mismatch.

Clinical value of serum JKAP in acute ischemic stroke patients.

BackgroundJun N‐terminal kinase pathway‐associated phosphatase (JKAP) regulates neuronal function, T helper (Th) 1/2/17 cell differentiation, and inflammatory process, but its clinical role in acute ischemic stroke (AIS) patients remains unclear. Hence, this study intended to evaluate JKAP level and its relationship with disease severity, Th1, 2, 17 secreted cytokines, adhesion molecules, and prognosis of AIS patients.MethodsSerum JKAP of 122 AIS patients and 50 controls was detected by ELISA. For AIS patients only, Th1, 2, 17 secreted cytokines IFN‐γ, IL‐4, IL‐17; TNF‐α, ICAM‐1, and VCAM‐1 were also detected by ELISA.ResultsJKAP was decreased in AIS patients compared with controls (46.350 (interquartile range (IQR): 34.250–59.875) pg/ml vs. 84.500 (IQR: 63.175–113.275) pg/ml, p < 0.001), which could distinguish AIS patients from controls (area under curve (AUC): 0.810, 95% confidence interval (CI): 0.732–0.888). In AIS patients, JKAP negatively linked with the National Institutes of Health Stroke Scale (NIHSS) score (rs = −0.342, p < 0.001); besides, it was positively related to IL‐4 (rs = 0.213, p = 0.018) and negatively associated with IL‐17 (rs = −0.270, p = 0.003) but not related to IFN‐γ (rs = −0.146, p = 0.109). Furthermore, elevated JKAP associated with declined TNF‐α (rs = −0.219, p = 0.015) and ICAM‐1 (rs = −0.235, p = 0.009) but not related to VCAM‐1 (rs = −0.156, p = 0.085). Besides, declined JKAP was linked with 2‐year recurrence (p = 0.027) and 3‐year recurrence (p = 0.010) in AIS patients; while JKAP was not related to 1‐year recurrence or death risk (both p > 0.050).ConclusionJKAP may sever as a candidate prognostic biomarker in AIS patients, indicating its potency for AIS management.

A review of mechanical thrombectomy techniques for acute ischemic stroke.

Mechanical thrombectomy is established as standard of care in the management of acute ischemic stroke due to large vessel occlusion and evidence-based guidelines for mechanical thrombectomy have been defined. As research continues to further expand the eligibility criteria for thrombectomy and the number of thrombectomy procedures increase worldwide, there is also growing focus on innovation of thrombectomy devices, procedural techniques, and related outcomes. Thrombectomy primarily involves use of stent retrievers and distal aspiration techniques, but variations and different combinations of techniques have been reported. As this is a rapidly evolving area in stroke management, there is debate as to which, if any, of these techniques leads to improved clinical outcomes over another and there is a lack of data comparing them. In this review, currently published and distinct techniques of mechanical thrombectomy are described methodically along with illustrations to aid in understanding the subtle differences between the techniques. The perceived benefits of each variation are discussed.

Low-Molecular-Weight Heparin Versus Aspirin in Early Management of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

ObjectivesTo evaluate the difference between low-molecular-weight heparin (LMWH) and aspirin in preventing early neurological deterioration (END) and recurrent ischemic stroke (RIS), post-recovery independence, and safety outcomes in acute ischemic stroke.Materials and MethodsWe performed systematic searches of the PubMed, Embase, Web of Science, and Cochrane Library databases for full-text articles of randomized controlled trials (RCTs) of LMWH vs. aspirin in the early management of acute ischemic stroke. Information on study design, eligibility criteria, baseline information, and outcomes was extracted. Synthesized relative risks (RRs) with 95% confidence intervals (CIs) are used to present the differences between the two treatments based on fixed-effects models.ResultsFive RCTs were retrieved from the online databases. The results showed no significant difference in efficacy outcomes between the two groups among unselected patients. Subgroup analysis showed that LMWH was significantly related to a lower incidence of END events [relative risk (RR): 0.44, 95% confidence interval (CI): 0.35–0.56] and reduced occurrence of RIS during treatment (OR: 0.34, 95% CI: 0.16–0.75) in non-cardioembolic stroke. LMWH significantly increased the number of patients with a modified Rankin scale (mRS) score of 0–1 at 6 months in patients with large-artery occlusive disease (LAOD) (RR: 0.50, 95% CI: 0.27–0.91). LMWH had a similar effect on symptomatic intracranial hemorrhage (sICH) and major extracranial hemorrhage during treatment to that of aspirin, except that LMWH was related to an increased likelihood of extracranial hemorrhage.ConclusionsIn patients with acute non-cardioembolic ischemic stroke, especially that with large-artery stenosis, LMWH treatment significantly reduced the incidence of END and RIS, and improved the likelihood of independence (mRS 0–1) at 6 months compared with those with aspirin treatment. LMWH was related to an increased likelihood of extracranial hemorrhage among all patients; however, the difference in major extracranial hemorrhage and sICH was not significant. Choosing the appropriate patients and paying attention to the start time and duration of treatment are very important in the use of anticoagulation.Systematic Review Registration http://www.crd.york.ac.uk/PROSPERO, identifier CRD42020185446.

Nutrition in acute stroke management: food for thought

Nutrition is crucial in the management of patients with acute stroke. 1 Dziewas R Michou E Trapl-Grundschober M et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J. 2021; 6: LXXXIX-LXXCXV Crossref PubMed Scopus (0) Google Scholar Clinical features putting patients at risk of malnutrition include dysphagia, impaired consciousness, perception deficits, and cognitive dysfunction. Being malnourished or at risk of malnutrition on admission to hospital after stroke is linked with poor functional outcomes and mortality, and worsening of nutritional status during the acute stage post-stroke is associated with similar adverse outcomes. 2 Dennis M Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD trial. Stroke. 2003; 34: 1450-1456 Crossref PubMed Scopus (0) Google Scholar Therefore, guidelines dedicated to acute stroke care generally include nutritional management. 1 Dziewas R Michou E Trapl-Grundschober M et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J. 2021; 6: LXXXIX-LXXCXV Crossref PubMed Scopus (0) Google Scholar , 3 Powers WJ Rabinstein AA Ackerson T et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019; 50: e344-e418 Crossref PubMed Scopus (1816) Google Scholar , 4 Boulanger JM Lindsay MP Gubitz G et al. Canadian stroke best practice recommendations for acute stroke management: prehospital, emergency department, and acute inpatient stroke care, 6th edition, update 2018. Int J Stroke. 2018; 13: 949-984 Crossref PubMed Scopus (154) Google Scholar , 5 Burgos R Bretón I Cereda E et al. ESPEN guideline clinical nutrition in neurology. Clin Nutr. 2018; 37: 354-396 Summary Full Text Full Text PDF PubMed Scopus (175) Google Scholar The guideline for the diagnosis and treatment of post-stroke dysphagia from the European Stroke Organization and European Society for Swallowing Disorders, for example, recommends early enteral nutrition via a nasogastric tube if sufficient oral nutrition is not possible. 1 Dziewas R Michou E Trapl-Grundschober M et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J. 2021; 6: LXXXIX-LXXCXV Crossref PubMed Scopus (0) Google Scholar This recommendation relies mainly on the second substudy of the Feed or Ordinary Diet (FOOD) trial, in which 859 patients with dysphagia after stroke were randomly assigned to either early tube feeding or delayed feeding starting later than 7 days after random assignment. Allocation to early tube feeding was associated with a non-significant reduction in mortality by 5·8% (there were 182 deaths in 429 patients randomly assigned to early tube feeding vs 207 deaths in 430 patients in the delayed feeding group; p=0·09). There were no differences in other outcomes, including severe disability or death (339 of 429 patients in the early-feeding group vs 344 of 430 patients in the delayed feeding group; p=0·7), pneumonia (132 of 429 patients in the early-feeding group vs 133 of 430 patients in the delayed feeding group; p>0·9), and percutaneous endoscopic gastrostomy placement at follow-up (30 of 429 patients in the early-feeding group vs 23 of 430 patients in the delayed feeding group). 6 Dennis M Lewis S Cranswick G Forbes J FOOD: a multicentre randomised trial evaluating feeding policies in patients admitted to hospital with a recent stroke. Health Technol Assess. 2006; 10: 1-120 Crossref Google Scholar Safety and efficacy of three enteral feeding strategies in patients with severe stroke in China (OPENS): a multicentre, prospective, randomised, open-label, blinded-endpoint trialIn the early phase of severe stroke, modified full enteral nutrition or hypocaloric enteral nutrition did not significantly reduce the risk of a poor outcomes compared with full enteral nutrition over a 90-day period. Hypocaloric enteral nutrition might be associated with increased mortality compared with modified full enteral nutrition. Further studies are needed to investigate whether modified full enteral nutrition might be the optimal strategy. Full-Text PDF

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.

Endovascular Intervention in Acute Ischemic Stroke: History and Evolution.

Stroke is a leading cause of serious long-term disability in the US. Endovascular therapy (EVT), in the form of mechanical thrombectomy, is now a standard of care for patients with acute ischemic stroke with a large vessel occlusion. This article reviews the evolution of EVT in the management of acute ischemic stroke and how it has led to the concept of tissue window over the widely publicized time window.