Use Of Endovascular Thrombectomy Research Articles

Does the Ischemic Core Really Matter? An Updated Systematic Review and Meta‐Analysis of Large Core Trials After TESLA, TENSION, and LASTE

Background The available evidence supporting the use of endovascular thrombectomy (EVT) in acute ischemic stroke patients with large core has increased with the recent release of the Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke (TESLA), Efficacy and Safety of Thrombectomy In Stroke with Extended Lesion and Extended Time Window (TENSION), and Large Stroke Therapy Evaluation (LASTE) trials, providing critical information on additional subgroups not included in initial trials. We aimed to study the efficacy and safety of EVT in patients with acute ischemic stroke with large core and stratify by several subgroups including core infarct at presentation, using a comprehensive meta‐analysis of aggregate data. Methods We executed a systematic search to identify randomized controlled trials that compared EVT to medical management (MM) for the treatment of patients with acute ischemic stroke with large core, defined as Alberta Stroke Program Early CT [Computed Tomography] Score ≤5 on noncontrast CT and/or estimated ischemic core ≥50 mL on CT‐perfusion/MR diffusion. The primary outcome was the shift analysis in the 90‐day modified Rankin scale (mRS) score. Secondary outcomes included functional independence (mRS score 0–2), independent ambulation (mRS score 0–3), 90‐day mortality, and symptomatic intracranial hemorrhage. Pooled odds ratios were calculated for shift mRS score through the random‐effects meta‐analyses, and risk ratios (RRs) were used for the other outcomes, comparing EVT with MM alone. Results Out of 3402 titles and abstracts screened, 6 randomized controlled trials with 1886 patients were included. The EVT group had a higher shift toward a lower mRS than MM alone (odds ratio [OR], 1.49 [95% CI, 1.24–1.79]). Furthermore, the use of EVT was associated with higher rates of functional independence (19.5% versus 7.5%, RR, 2.49 [95% CI, 1.92–3.24]), independent ambulation (36.5% versus 19.9%, RR, 1.91 [95% CI, 1.51–2.43]), and symptomatic intracranial hemorrhage (5.5% versus 3.2%, RR, 1.73 [95% CI, 1.01–2.95]) compared with MM. There was no difference between the 2 groups regarding mortality (31.5% versus 36.8%, RR, 0.86 [95% CI, 0.72–1.02]). Importantly, EVT was consistently associated with a shift toward a lower mRS score in both Alberta Stroke Program Early CT Score 3–5 (OR, 1.60 [95% CI, 1.10–2.32]) and Alberta Stroke Program Early CT Score 0–2 (OR, 1.45 [95% CI, 1.17–1.80]) when compared with MM alone. Conclusion Our results confirm the efficacy of EVT for acute ischemic stroke with large core and suggest a consistent benefit across all Alberta Stroke Program Early CT Score categories. These results represent an important shift in the current large vessel occlusion selection paradigm that currently considers core as an effect modifier for EVT selection.

Factors Predicting the Use of Endovascular Thrombectomy Following Acute Ischemic Stroke in Adults with Chronic Atrial Fibrillation (P9-5.020)

Factors Predicting the Use of Endovascular Thrombectomy Following Acute Ischemic Stroke in Adults with Chronic Atrial Fibrillation (P9-5.020)

Endovascular thrombectomy for large ischemic strokes: meta-analysis of six multicenter randomized controlled trials

BackgroundSix randomized controlled trials have concluded their investigations on the efficacy and safety of endovascular thrombectomy (EVT) for patients with large infarcts.To synthesize the results from six trials which met...

Reperfusion therapies for ischemic stroke in dementia and cognitive impairment: A systematic review and meta-analysis.

Endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) have an unclear benefit in those with pre-stroke dementia or cognitive impairment, as these patients were often excluded from landmark stroke trials. We performed a systematic review and meta-analysis to assess the outcomes of IVT and EVT in these populations. Our systematic review, conforming to the Meta-Analysis of Observational Studies in Epidemiology guidelines, investigated studies on acute ischemic stroke patients with pre-stroke dementia or cognitive impairment treated with IVT or EVT. Primary outcome was favorable 90-day outcome (mRS 0-2). Secondary outcomes included 90-day mortality, symptomatic intracranial hemorrhage (SICH), and radiographic intracranial hemorrhage (ICH). Nine articles were identified, with five observational studies of IVT use in patients with (n = 1078) and without dementia (n = 2805) being selected for the meta-analysis. There were no significant differences in favorable outcome (adjusted OR: 0.61, 95% CI 0.24-1.59), mortality (unadjusted OR: 1.19, 95% CI 0.86-1.64), ICH (unadjusted OR: 1.32, 95% CI 0.79-2.19), and symptomatic ICH (unadjusted OR: 0.94, 95% CI 0.70-1.25) for patients undergoing IVT with pre-stroke dementia versus those without. One EVT study (n = 615 with dementia vs n = 9600 without) found no significant differences in outcomes apart from an increased odds of ICH for those with pre-existing dementia (adjusted OR: 1.57, 95% CI 1.03-2.40). A pooled analysis of three IVT studies showed no significant association of cognitive impairment (n = 93 vs n = 211 without) with all assessed outcomes, whereas a study of EVT found that pre-stroke cognitive impairment was associated with poor 90-day outcomes (mRS 3-6). These results suggest no substantial safety issues in the use of IVT or EVT for patients with pre-existing dementia or cognitive impairment compared to those without. However, the efficacy of these therapies in this demographic remains uncertain. Further rigorous studies that include a more nuanced outcome measurement approach are warranted. URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021240499.

Abstract 195: Changing Trends of Thrombolysis and Thrombectomy for Low Severity Stroke: National Inpatient Sample Analysis (2016‐2020)

Introduction Over the past decade, stroke management has significantly improved with the widespread use of intravenous thrombolysis (IVT) and the establishment of endovascular thrombectomy (EVT) as the standard of care for increasing patients. However, a dilemma arises in cases of low‐severity stroke (NIHSS ≤ 5), as the EVT clinical trials do not include patients with such low NIHSS. There is debate surrounding the topic of EVT and IVT for low‐severity stroke, and often practice does not reflect the patient populations included in the initial clinical trials. Some recent studies suggest a trend toward decreasing pre‐thrombectomy IVT. (1) This study aims to examine the evolving trends of intravenous thrombolysis (IVT), endovascular thrombectomy (EVT), and their combination in low NIHSS acute ischemic stroke (AIS) management in the United States from 2016 to 2020. Methods We accessed the national inpatient sample database from 2016 through 2020. We included patients admitted with stroke and who had a recorded NIHSS ≤ 5. To determine if there were changes in the frequency of events over time, we compared the outcome measures utilizing logistic regression models with 2016 as the reference year. Results Compared to 2016 the rates of IVT have significantly decreased starting in 2018 through 2020. The rates of EVT have trended upward since 2016 and were significantly higher in the year 2020. The rates of thrombectomy plus thrombolysis have trended upward but have not significantly changed since 2016. These results can be visualized in the Figure below, * = p‐value < 0.05. Conclusion Our findings highlight a significant shift in stroke treatment, with the growing use of EVT while simultaneously decreasing rates of IVT for low‐NIHSS strokes. Current clinical trials protocol are submitted to examine EVT's efficacy for low NIHSS stroke (2), but it's also crucial to understand what is driving this change in real‐world practice. This understanding will inform treatment decisions and ensure they align with evidence‐based standards, guaranteeing optimal, standardized patient care.

Racial and ethnic disparities in the usage and outcomes of ischemic stroke treatment in the United States

ObjectivesThis study explores racial and ethnic differences in 1) receiving tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT) as treatment for ischemic stroke and 2) outcomes and quality of care after use of tPA or EVT in the US. Materials and MethodsAn observational analysis of 89,035 ischemic stroke patients from the 2019 National Inpatient Sample was conducted. We performed weighted logistic regressions between race and ethnicity and 1) tPA and EVT utilization and 2) in-hospital mortality. We also performed a weighted Poisson regression between race and ethnicity and length of stay (LOS) after tPA or EVT. ResultsNon-Hispanic (NH) Black patients had significantly lower odds of receiving tPA (Adjusted odds ratio [AOR] = 0.85, 95 % Confidence Internal [C.I.]: 0.80-0.91) and EVT (AOR = 0.75, 95 % CI: 0.70-0.82) than NH White patients. Minority populations (including but not limited to NH Black, Hispanic, Pacific Islander, Native American, and Asian) had significantly longer hospital LOS after treatment with tPA or EVT. We did not find a significant difference between race/ethnicity and in-hospital mortality post-tPA or EVT. ConclusionsWhile we failed to find a difference in in-hospital mortality, racial and ethnic disparities are still evident in the decreased usage of tPA and EVT and longer LOSs for racial and ethnic minority patients. This study calls for interventions to expand the utilization of tPA and EVT and advance quality of care post-tPA or EVT in order to improve stroke care for minority patients.

June 2023 Stroke Highlights.

June 2023 Stroke Highlights.

A retrospect and outlook on the neuroprotective effects of anesthetics in the era of endovascular therapy.

Studies on the neuroprotective effects of anesthetics were carried out more than half a century ago. Subsequently, many cell and animal experiments attempted to verify the findings. However, in clinical trials, the neuroprotective effects of anesthetics were not observed. These contradictory results suggest a mismatch between basic research and clinical trials. The Stroke Therapy Academic Industry Roundtable X (STAIR) proposed that the emergence of endovascular thrombectomy (EVT) would provide a proper platform to verify the neuroprotective effects of anesthetics because the haemodynamics of patients undergoing EVT is very close to the ischaemia-reperfusion model in basic research. With the widespread use of EVT, it is necessary for us to re-examine the neuroprotective effects of anesthetics to guide the use of anesthetics during EVT because the choice of anesthesia is still based on team experience without definite guidelines. In this paper, we describe the research status of anesthesia in EVT and summarize the neuroprotective mechanisms of some anesthetics. Then, we focus on the contradictory results between clinical trials and basic research and discuss the causes. Finally, we provide an outlook on the neuroprotective effects of anesthetics in the era of endovascular therapy.

Prior anticoagulation and bridging thrombolysis improve outcomes in patients with atrial fibrillation undergoing endovascular thrombectomy for anterior circulation stroke

BackgroundWhere stroke occurs with pre-existing atrial fibrillation (AF)studies validating the safety and efficacy of bridging thrombolysis, and the use of endovascular thrombectomy (EVT) in the setting of prior anticoagulation, are...

Abstract Number ‐ 190: Acute Ischemic Stroke patients post Endovascular Thrombectomy complicated by gastrointestinal bleeding have worst clinical outcomes

Introduction The objective of this study was to scrutinize the stroke severity markers, complications, and clinical outcomes in patients with AIS who underwent EVT complicated by gastrointestinal bleeding (GIB). It is known that anemia is associated with poor functional outcomes in patients with mechanical thrombectomy (Nisar, 2021). Anemia also predicts poor clinical outcomes despite fair or good collateral circulation (Pienimäki, 2020). With the increasing use of EVT for acute management of AIS, it is prudent to investigate the relationship between gastrointestinal bleeding in acute ischemic stroke patients who have underwent mechanical thrombectomy. Methods The 2016–2019 National Inpatient Sample (NIS) database was queried for patients with the diagnosis of acute ischemic stroke (AIS) by using International Classification of Disease, 10threvision (ICD10) diagnosis codes. From this cohort of AIS patients, those that underwent endovascular thrombectomy (EVT) were then identified using ICD 10 procedure codes. A subpopulation of AIS‐EVT patients was created for patients with a diagnosis of GI bleeds. Baseline demographic, stroke severity, complication, and outcome variables were evaluated between GI bleed and no‐GI bleed patients who underwent EVT. Results Of 132,210 patients hospitalized for AIS who had underwent EVT, there were 130,970 cases of no GIB (99.1% %) and 1,240 cases of GIB (0.9%) complications. Mean age greater than 65 was 980 (79%) in GI bleed group versus 82,945 (63.3%) in no GI bleed group (p‐value < 0.001, CI 95%: 1.903 ‐ 2.5, OR 2.2). Interestingly, the no GI bleed group had more use of Aspirin 31,790 (24.3%) versus GI bleed group 200 (16.1%) (p‐value < 0.001, CI 95%: 0.515 ‐ 0.698, OR 0.6). Furthermore, the GI bleed group had the following risk factors that were statistically significant: history of atrial fibrillation and chronic renal failure (46% vs 37.2% and 21.8% vs 15.1%, respectively). In fact, this study failed to show increased risk of GI bleed due to being on aspirin, AC, having a history of DM, HTN, HLD, and CHF. Stroke severity was worst in GI bleed group with average NIHSS score 15.92 vs 14.05 (P‐value < 0.001) and worst hemiplegia (75% vs 70.2%, P‐value < 0.001, 1.3 CI 1.118‐1.447). The GI bleed group had statistically worst complications including sepsis, DVT, PE, AKI, and aspiration pneumonia. Lastly, the GI bleed patients were most likely to be discharged to SNF versus routine discharge to home (68.5% vs 49.6%, p‐value < 0.001, CI 1,962 ‐ 2.496, OR 2.2). Conclusions GIB occurrence in patients with AIS status post EVT is relatively rare but is associated with poor in‐hospital outcomes, including mortality. We identified risk factors associated with GIB in AIS post EVT, which allows physicians to monitor patient populations at the highest risk.

Abstract Number ‐ 6: Basilar Artery Occlusion Thrombectomy Technique: An International Survey of Practice Patterns

Introduction Two recent trials demonstrated a benefit for endovascular thrombectomy (EVT) in the treatment of basilar artery occlusion (BAO). Considering the expected increase in the utilization of EVT for BAO, we sought to understand the technique preferences of neurointerventionalists currently performing EVT for BAO. Methods We conducted an international online survey of physician opinions on the use of EVT in BAO between January to March 2022. The survey was distributed through stroke and neurointerventional organizations. Survey questions examined selection of patients for the procedure and the techniques currently used for EVT in BAO. Results More than 3,000 participants were invited yielding 1,245 respondents, of which 543 were classified as neurointerventionalists across 52 countries and included in this analysis. Most neurointerventionalists would proceed to EVT for occlusions of the V4 segment, the basilar artery, or the PCA, without regard for prior IVT. For BAO of embolic etiology, aspiration only thrombectomy was the preferred method with 50.3% of neurointerventionalists. For BAO of intracranial atherosclerotic disease (ICAD) etiology, combined stent retriever and aspiration thrombectomy was the preferred method with 40.5% of neurointerventionalists (Figure 1). The majority of neurointerventionalists (88.0%) would proceed to stenting after three or fewer failed passes for patients with BAO of ICAD etiology. In patients undergoing stenting, aspirin and clopidogrel was the most common antiplatelet regime (52.4%). Conclusions Amongst the surveyed neurointerventionalists, the most common techniques for EVT of patients with BAO were contact aspiration or combined stent retriever with aspiration thrombectomy. For patients with BAO due to ICAD, the majority of neurointerventionalists were willing to stent and do so most often after three or fewer failed passes and with the use of dual antiplatelet medications. Further study is needed to determine the optimal technique for EVT of BAO with or without ICAD.

Stroke Thrombectomy in the Elderly: Efficacy, Safety, and Special Considerations

Background Elderly patients account for a major Q2 proportion of ischemic strokes worldwide, and the use of endovascular thrombectomy (EVT) for the elderly has been increasing in recent years. Major clinical trials have demonstrated the benefit of EVT for the general population; however, the degree of benefit is less clear in elderly populations. Although EVT is generally considered safe and effective in healthy elderly adults, there remains controversy as to whether EVT should be offered to all elderly patients, and optimal patient selection and management strategies remain elusive. Methods This review consolidates the current literature on the overall efficacy and safety of EVT in the elderly population and highlights multiple topics that are particularly relevant to elderly populations. Results/Conclusions Topics discussed include quality of life, patient selection strategies, white matter disease burden, reperfusion of large ischemic cores, bridging thrombolysis, prethrombectomy imaging, as well as technical considerations.

Endovascular thrombectomy is beneficial for functional nonagenarians – a multicenter cohort analysis

IntroductionThe use of endovascular thrombectomy (EVT) has dramatically increased in recent years. However, most existing studies used an upper age limit of 80 and data regarding the safety and efficacy of EVT among nonagenarians is still lacking. Methods767 consecutive patients undergoing EVT for large vessel occlusion (LVO) in three participating centers were recruited into a prospective ongoing database. Demographic, clinical and imaging characteristics were documented. Statistical analysis was done to evaluate EVT outcome among nonagenarians compared to younger patients. ResultsThe current analysis included 41 (5.4%) patients older than 90 years. Compared to younger patients, nonagenarians were more often female (78% versus 50.3%, p ≤ 0.001), had worse baseline mRS scores (2 [0–3] versus 0 [0–2], p < 0.001), higher rates of hypertension and hyperlipidemia and a higher admission NIHSS (20 [14–23] versus 16 [11–20], p < 0.001). No differences were found between groups regarding the involved vessel, stroke etiology, time from symptoms to door or symptoms to EVT, successful recanalization rates and hemorrhagic transformation rates. Nonagenarians had worse mRS at 90 days (5 [3–6] versus 3 [2–5], p = 0.001), similar discharge NIHSS (5 [1–11] versus 4 [1–11], p = 0.78) and higher mortality rates (36.6% versus 15.8%, p < 0.001). All nonagenarians with baseline mRS 4 have died within 90 days. 36.4% of nonagenarian patients with baseline MRS of 3 or less had favorable outcome. DiscussionThis study demonstrates that nonagenarian stroke patients with baseline mRS of 3 or less benefit from EVT with no significant difference in the rate of favorable outcome compared to octogenarians.

Associations Between Adherence to Evidence-Based, Stroke Quality Indicators and Outcomes of Acute Reperfusion Therapy.

Background:Quality indicators (QIs) are an accepted tool for measuring a hospital’s performance in routine care. We examined national trends in adherence to the QIs developed by the Close The Gap-Stroke program by combining data from the health insurance claims database and electronic medical records, and the association between adherence to these QIs and early outcomes in patients with acute ischemic stroke in Japan.Methods:In the present study, patients with acute ischemic stroke who received acute reperfusion therapy in 351 Close The Gap-Stroke-participating hospitals were analyzed retrospectively. The primary outcomes were changes in trends for adherence to the defined QIs by difference-in-difference analysis and the effects of adherence to distinct QIs on in-hospital outcomes at the individual level. A mixed logistic regression model was adjusted for patient and hospital characteristics (eg, age, sex, number of beds) and hospital units as random effects.Results:Between 2013 and 2017, 21 651 patients (median age, 77 years; 43.0% female) were assessed. Of the 25 defined measures, marked and sustainable improvement in the adherence rates was observed for door-to-needle time, door-to-puncture time, proper use of endovascular thrombectomy, and successful revascularization. The in-hospital mortality rate was 11.6%. Adherence to 14 QIs lowered the odds of in-hospital mortality (odds ratio [95% CI], door-to-needle <60 min, 0.80 [0.69–0.93], door-to-puncture <90 min, 0.80 [0.67–0.96], successful revascularization, 0.40 [0.34–0.48]), and adherence to 11 QIs increased the odds of functional independence (modified Rankin Scale score 0–2) at discharge.Conclusions:We demonstrated national marked and sustainable improvement in adherence to door-to-needle time, door-to-puncture time, and successful reperfusion from 2013 to 2017 in Japan in patients with acute ischemic stroke. Adhering to the key QIs substantially affected in-hospital outcomes, underlining the importance of monitoring the quality of care using evidence-based QIs and the nationwide Close The Gap-Stroke program.

Editors' Note: Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke: A MR CLEAN Registry Substudy

In “Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke: A MR CLEAN Registry Substudy,” Verschoof et al. reported that despite similar technical success, patients with active cancer who underwent endovascular thrombectomy (EVT) experienced worse functional outcomes and a higher risk of mortality 90 days poststroke than patients without active cancer. Moores and Ganesh noted that these findings are consistent with results from the ESCAPE and ESCAPE-NA1 trials and it remains unclear how to identify patients who meet existing selection criteria for EVT but have no potential for benefit from EVT because they experience active cancer. They emphasized the importance of shared decision-making in these challenging situations, particularly when workup for acute stroke uncovers a new diagnosis of cancer. Verschoof et al. responded that the ESCAPE and ESCAPE-NA1 trials included 4 patients with cancer but did not comment on whether it was active. Because of the difficulty forming conclusions about the use of EVT in patients with active cancer through observational studies, they recommended the need for a controlled trial to study EVT in patients with active cancer. In “Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke: A MR CLEAN Registry Substudy,” Verschoof et al. reported that despite similar technical success, patients with active cancer who underwent endovascular thrombectomy (EVT) experienced worse functional outcomes and a higher risk of mortality 90 days poststroke than patients without active cancer. Moores and Ganesh noted that these findings are consistent with results from the ESCAPE and ESCAPE-NA1 trials and it remains unclear how to identify patients who meet existing selection criteria for EVT but have no potential for benefit from EVT because they experience active cancer. They emphasized the importance of shared decision-making in these challenging situations, particularly when workup for acute stroke uncovers a new diagnosis of cancer. Verschoof et al. responded that the ESCAPE and ESCAPE-NA1 trials included 4 patients with cancer but did not comment on whether it was active. Because of the difficulty forming conclusions about the use of EVT in patients with active cancer through observational studies, they recommended the need for a controlled trial to study EVT in patients with active cancer.

Trends in Use, Outcomes, and Disparities in Endovascular Thrombectomy in US Patients With Stroke Aged 80 Years and Older Compared With Younger Patients

Patients aged 80 years and older were often excluded or underrepresented in pivotal endovascular thrombectomy (EVT) trials. Accordingly, trends in frequency, outcomes, and disparities of EVT use merit close analysis. To delineate temporal trends in EVT use, outcomes, and disparities among patients with acute ischemic stroke aged 80 years and older vs those younger than 80 years. A US nationwide retrospective cohort study using prospectively collected data was conducted in patients admitted with a primary diagnosis of acute ischemic stroke between April 1, 2012, and June 30, 2019. Data were obtained from hospitals participating in the Get With the Guidelines-Stroke (GWTG-Stroke) program, which is a stroke quality improvement registry, with data collected prospectively, sponsored by the American Heart Association/American Stroke Association. Data analysis was conducted from November 2, 2020, to June 25, 2021. Potentially eligible for EVT based on arrival within 6 hours and National Institutes of Health Stroke Scale score greater than or equal to 6. Efficacy outcomes included discharge to home, independent ambulation at discharge, and functional independence (modified Rankin Scale score 0-2) at discharge. Safety outcomes included in-hospital mortality, combined in-hospital mortality or discharge to hospice, and symptomatic intracranial hemorrhage. Among 302 965 patients with ischemic stroke meeting study criteria as potentially eligible for EVT admitted to 614 GWTG-Stroke hospitals, 14.0% (42 422) received EVT (21 634 women [51.0%]), including 10.7% (12 768 of 119 453) of patients aged 80 years and older (median [IQR] age, 85 [82-89] years) and 16.2% (29 654 of 183 512) of patients younger than 80 years (median [IQR] age, 65 [56-73] years). Among patients aged 80 years and older, EVT rates increased substantially during the study period, from 3.3% in early 2012 to 20.8% in early 2019. By study end, the relative rate of EVT among eligible patients aged 80 years and older compared with those younger than 80 years increased from 0.49 (3.3% vs 6.7%) to 0.76 (20.8% vs 27.3%). Older patients had worse outcomes at discharge compared with younger patients, including discharge to home: 12.5% vs 31.1% (adjusted odds ratio [aOR], 0.43; 95% CI, 0.40-0.46), functional independence (modified Rankin Scale score 0-2): 10.9% vs 26.6% (aOR, 0.45; 95% CI, 0.41-0.49), and inpatient death or discharge to hospice, 34.5% vs 16.1% (aOR, 2.22; 95% CI, 2.09-2.36). Symptomatic intracranial hemorrhage rates did not differ significantly (6.9% vs 6.5%; aOR, 1.04; 95% CI, 0.94-1.14). In this cohort study, use of EVT among individuals aged 80 years and older increased substantially from 2012 to 2019, although the rate remained lower than in younger patients. Although favorable functional outcomes at discharge were lower and combined mortality or discharge to hospice was higher in the older patients, the risk of symptomatic intracranial hemorrhage was not increased.

May 2022 Stroke Highlights

May 2022 <i>Stroke</i> Highlights

The influence of sex on ischemic stroke incidence, therapeutic procedures and in-hospital mortality: Results of the Spanish National Hospital Discharge.

Previous research has revealed sex-related differences in outcomes for people admitted to hospitals for ischemic stroke. We aimed to analyse the incidence, use of invasive procedures and in-hospital outcomes of ischemic stroke in Spain (2016-2018) using the Spanish National Hospital Discharge Database. We sought sex-related differences in incidence and in-hospital outcomes over time. We estimated the incidence of ischemic stroke in men and women. We analysed comorbidities (Charlson's comorbidity index, cardiovascular risk factors, alcohol abuse and atrial fibrillation), procedures (mechanical ventilation, endovascular thrombectomy and thrombolytic therapy) and outcomes. We matched each woman with a man with identical age, type of ischemic stroke and year of hospitalisation. We built Poisson regression models to obtain adjusted incidence rate ratios (IRRs). We tested in-hospital mortality (IHM) with logistic regression analyses. Ischemic stroke was coded in 172255 patients aged ≥35years (92524 men 53.7%). Men showed higher incidence rates (216.9 vs. 172.3/105 ; P<.001; IRR=1.57 (95% CI:1.55-1.59) than women. After matching, the use of endovascular thrombectomy (5.1% vs. 4.0%; P<.001) and thrombolytic therapy (7.6% vs. 6.8%; P<.001) was higher among women. IHM was significantly higher in women than in matched men (11.2% vs. 10.4%; P<.001). Women had a lower IHM than matched men when endovascular thrombectomy (9.4% vs. 12.1%; P=.001) or thrombolytic therapy (6.7% vs. 8.3%; P=.003) was coded. Patients of both sexes admitted for ischemic stroke who received thrombolytic therapy had lower IHM (OR=0.76; 95% CI:0.68-0.85 among men; and OR=0.58; 95% CI:0.52-0.64 among women), but endovascular thrombectomy was associated with a lower IHM only among women (OR=0.58; 95% CI:0.51-0.66). After multivariable adjusting, women admitted to the hospital for ischemic stroke had a significantly higher IHM than men (OR=1.16; 95% CI:1.12-1.21). Men had higher incidence rates of ischemic stroke than women. Women more often underwent thrombolytic therapy and endovascular thrombectomy but had a higher IHM.

Investigating the “Weekend Effect” on Outcomes of Patients Undergoing Endovascular Mechanical Thrombectomy for Ischemic Stroke

Objectives: With growing evidence of its efficacy for patients with large-vessel occlusion (LVO) ischemic stroke, the use of endovascular thrombectomy (EVT) has increased. The “weekend effect,” whereby patients presenting during weekends/off hours have worse clinical outcomes than those presenting during normal working hours, is a critical area of study in acute ischemic stroke (AIS). Our objective was to evaluate whether a “weekend effect” exists in patients undergoing EVT. MethodsThis retrospective, cross-sectional analysis of the 2016–2018 Nationwide Inpatient Sample data included patients ≥18 years with documented diagnosis of ischemic stroke (ICD-10 codes I63, I64, and H34.1), procedural code for EVT, and National Institutes of Health Stroke Scale (NIHSS) score; the exposure variable was weekend vs. weekday treatment. The primary outcome was in-hospital death; secondary outcomes were favorable discharge, extended hospital stay (LOS), and cost. Logistic regression models were constructed to determine predictors for outcomes. ResultsWe identified 6052 AIS patients who received EVT (mean age 68.7±14.8 years; 50.8% female; 70.8% White; median (IQR) admission NIHSS 16 (10-21). The primary outcome of in-hospital death occurred in 560 (11.1%); the secondary outcome of favorable discharge occurred in 1039 (20.6%). The mean LOS was 7.8±8.6 days. There were no significant differences in the outcomes or cost based on admission timing. In the mixed-effects models, we found no effect of weekend vs. weekday admission on in-hospital death, favorable discharge, or extended LOS. ConclusionThese results demonstrate that the “weekend effect” does not impact outcomes or cost for patients who undergo EVT for LVO.

Racial and Socioeconomic Disparities in the Use and Outcomes of Endovascular Thrombectomy for Acute Ischemic Stroke.

Racial and socioeconomic disparities in the incidence, treatment, and outcomes of acute ischemic stroke exist and have been described. We aimed to characterize disparities in the use of endovascular thrombectomy in a nationally representative analysis. Discharge data from the Nationwide Inpatient Sample between 2006 and 2016 were queried using validated International Classification of Disease codes. Patients admitted to US hospitals with acute ischemic stroke were included and stratified on the basis of race, income, and primary payer. Trends in endovascular thrombectomy use, good outcome (discharge to home/acute rehabilitation), and poor outcome (discharge to skilled nursing facility, hospice, in-hospital mortality) were studied using univariate and multivariable analyses. In this analysis of 1,322,162 patients, endovascular thrombectomy use increased from 53/111,829 (0.05%) to 3054/146,650 (2.08%) between 2006 and 2016, respectively. Less increase was observed in black patients from 4/12,733 (0.03%) to 401/23,836 (1.68%) and those in the lowest income quartile from 10/819 (0.03%) to 819/44,984 (1.49%). Greater increase was observed in the highest income quartile from 18/22,138 (0.08%) to 669/27,991 (2.39%). Black race predicted less endovascular thrombectomy use (OR = 0.79; 95% CI, 0.72-0.86). The highest income group predicted endovascular thrombectomy use (OR = 1.24; 95% CI, 1.13-1.36) as did private insurance (OR = 1.30; 95% CI, 1.23-1.38). High income predicted good outcome (OR = 1.10; 95% CI. 1.06-1.14), as did private insurance (OR = 1.36; 95% CI, 1.31-1.39). Black race predicted poor outcome (OR = 1.33; 95% CI, 1.30-1.36). All results were statistically significant (P < .01). Despite a widespread increase in endovascular thrombectomy use, black and low-income patients may be less likely to receive endovascular thrombectomy. Future effort should attempt to better understand the causes of these disparities and develop strategies to ensure equitable access to potentially life-saving treatment.