Stroke; a journal of cerebral circulation
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Background and Purpose- The Ottawa subarachnoid hemorrhage (SAH) rule identifies patients with headache requiring no testing for SAH, while the 6-hour computed tomography (CT) rule guides when to forgo a lumbar puncture. Our objectives were to: (1) estimate the clinical impact of the Ottawa SAH rule and the 6-hour-CT rule on testing rates (ie, CT, lumbar puncture, CT angiography); (2) validate the 6-hour-CT rule for SAH when applied prospectively in a new cohort of patients. Methods- We conducted a multicenter prospective before/after implementation study from 2011 to 2016 with 6 months follow-up at 6 tertiary-care Canadian Academic Emergency Departments. ⋯ The 6-hour-CT rule missed 5 SAHs: 1 radiology misread, 2 incidental aneurysms, 1 nonaneurysmal cause, and 1 profoundly anemic patient. Conclusions- The Ottawa SAH rule and the 6-hour-CT rule are highly sensitive and can be used routinely when SAH is considered in patients with headache. Implementing both rules was associated with a meaningful decrease in testing and admissions to hospital.
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Background and Purpose- Cerebral edema (CED) develops in the hours to days after stroke; the resulting increase in brain volume may lead to midline shift (MLS) and neurological deterioration. The time course and implications of edema formation are not well characterized across the spectrum of stroke. We analyzed displacement of cerebrospinal fluid (ΔCSF) as a dynamic quantitative imaging biomarker of edema formation. ⋯ Risk of CED almost doubled for every 10% ΔCSF within 24 hours (odds ratio, 1.76 [95% CI, 1.46-2.14]), adjusting for age, glucose, and National Institutes of Health Stroke Scale. Risk of neurological deterioration (1.6-point increase in National Institutes of Health Stroke Scale at 24 hours) and poor outcome (adjusted odds ratio, 1.34 [95% CI, 1.15-1.56]) was also greater for every 10% increase in ΔCSF. Conclusions- CSF volumetrics provides quantitative evaluation of early edema formation. ΔCSF from baseline to 24-hour computed tomography is a promising early biomarker for the development of MLS and worse neurological outcome.
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Background and Purpose- The purpose of this study was to conduct a meta-analysis of CVOTs (cardiovascular outcome trials) to evaluate the effect of glucagon-like peptide-1 receptor agonists therapy in reducing the risk of stroke in patients with type 2 diabetes mellitus. Methods- PubMed and other electronic sources were searched until June 20, 2019, to identify relevant studies. Hazard ratios with 95% CIs were used as a measure of the association between use of glucagon-like peptide-1 receptor agonists and risk of stroke after pooling data across trials. ⋯ Use of glucagon-like peptide-1 receptor agonists in patients with type 2 diabetes mellitus was associated with 15% lower risk of nonfatal stroke (P=0.002), 19% lower risk of fatal stroke (P=0.150), and 16% lower risk of total stroke (P=0.001). There was no association between reductions of hemoglobin A1c levels or body weight and risk of stroke. Conclusions- Glucagon-like peptide-1 receptor agonists reduce the risk of nonfatal stroke in patients with T2D.
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Background and Purpose- Clinical deficits from ischemic stroke are more severe in women, but the pathophysiological basis of this sex difference is unknown. Sex differences in core and penumbral volumes and their relation to outcome were assessed in this substudy of the DEFUSE 3 clinical trial (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke). Methods- DEFUSE 3 randomized patients to thrombectomy or medical management who presented 6 to 16 hours from last known well with proximal middle cerebral artery or internal carotid artery occlusion and had target core and perfusion mismatch volumes on computed tomography or magnetic resonance imaging. ⋯ These observations suggest sex differences in hemodynamic and temporal features of anterior circulation large artery occlusions. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT02586415.
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Clinical Trial
Ethnicity and Other Determinants of Quality of Functional Outcome in Acute Ischemic Stroke: The ENCHANTED Trial.
Background and Purpose- Patient-centered outcomes are important. We aimed to determine predictors of health-related quality of life (HRQoL) and develop utility-weighted modified Rankin Scale (mRS) scores in thrombolyzed acute ischemic stroke patients from both arms of ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study). Methods- ENCHANTED was an international quasi-factorial clinical trial of different doses of intravenous alteplase and intensities of blood pressure control in acute ischemic stroke patients, with outcomes on the 5-Dimensional European Quality of Life Scale and mRS assessed at 90 days post-randomization. ⋯ From utility-weighted mRS scores indicating the greatest steps in mRS scores are between 5 and 3, treatments to avoid major disability provide the greatest benefits for patients. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT01422616.