Abstract TP36: Impact of Intracranial Hemorrhage After Endovascular Treatment on Long-Term Functional Outcomes in Patients With Acute Large Vessel Occlusion: Insights From RESCUE- Japan Registry-2

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Norito Kinjo ◽  
Kazutaka Uchida ◽  
Shinichi Yoshimura ◽  
Nobuyuki Sakai ◽  
Hiroshi Yamagami ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Intracranial Hemorrhage ◽  
Functional Outcomes ◽  
Large Vessel ◽  
Prognostic Impact ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
The Impact

Background and Purpose: Endovascular therapy (EVT) for acute large vessel occlusion (LVO) is currently standard therapy, but it was associated with a higher incidence of intracranial hemorrhage (ICH) compared to conservative therapy. We investigated the impact of ICH within 72 hours on functional outcome at 90 days in patients with EVT for acute LVO. Methods: RESCUE-Japan Registry-2 was a multicenter registry enrolled 2420 consecutive patients with acute LVO within 24 hours of onset. We analyzed patients who received EVT and compared the functional outcomes between those with ICH (ICH group) and without ICH (No-ICH group) within 72 hours after onset. We estimated the adjusted odds ratio (OR) for good functional outcome as mRS 0-2 and mortality. We also explored the prognostic impact of symptomatic ICH (SICH) among those with ICH. Results: Among 2420 patients in the registry, 1281 received EVT and mean age was 75 years, and 759 (59.2%) were men. ICH occurred in 332 patients (25.9%). Good outcome was observed 80 patients (24.0%) and 454 patients (47.9%) in the ICH and No-ICH group, respectively, and the adjusted OR for good outcome of ICH group compared to No-ICH group was 0.30 (95% CI 0.22-0.42, p<0.0001). However, the mortalities within 90 days were not significantly different between groups (adjusted OR 1.13; 95% CI 0.72-1.76, p=0.59). SICH was observed in 35 patients (10.5%) among 332 patients with ICH, and the good outcomes were 8.6% and 25.9 % in patients with SICH and asymptomatic ICH (AICH), respectively (p=0.02). Mortality at 90 days were 31.4% and 7.0% in patients with SICH and AICH, respectively (p<0.0001). Conclusion: The functional outcomes at 90 days after onset was significantly worse in patients suffered ICH than the counterparts after EVT for acute LVO. However, the mortality rates were generally similar between those with and without ICH. Among patients with ICH, mortality was higher in patients with SICH, but mortality of the patients with AICH was similar to those without ICH.

Incidence and Prognostic Impact of Intracranial Hemorrhage after Endovascular Treatment for Acute Large Vessel Occlusion

2020 ◽  
Vol 49 (5) ◽  
pp. 540-549
Author(s):  
Norito Kinjo ◽  
Shinichi Yoshimura ◽  
Kazutaka Uchida ◽  
Nobuyuki Sakai ◽  
Hiroshi Yamagami ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Functional Outcome ◽  
Intracranial Hemorrhage ◽  
Functional Outcomes ◽  
Large Vessel ◽  
Prognostic Impact ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Scale Scores ◽  
The Impact

<b><i>Introduction:</i></b> Endovascular treatment (EVT) is effective against acute cerebral large vessel occlusion (LVO). However, it has been associated with a high incidence of intracranial hemorrhage (ICH). Because the incidence of ICH and prognostic impact of ICH were not scrutinized in general patients, we investigated the impact of ICH after EVT on functional outcome at 90 days in patients with acute LVO. <b><i>Methods:</i></b> RESCUE-Japan Registry 2 was a multicenter registry that enrolled 2,420 consecutive patients with acute LVO within 24 h of onset. We analyzed 1,281 patients who received EVT and compared the functional outcomes between those with and without ICH (ICH and no-ICH groups, respectively) within 24 h after EVT. We explored the factors associated with ICH and prognostic impact of symptomatic ICH (SICH) among patients with ICH. We estimated the adjusted odds ratios (ORs) for good functional outcome as modified Rankin Scale scores 0–2 and mortality. We also explored the prognostic impact of symptomatic ICH (SICH) among patients with ICH. <b><i>Results:</i></b> ICH occurred in 333 patients (26.0%). Several factors such as perioperative edaravone, stent retriever, and baseline glucose were associated with development of ICH within 24 h. A good outcome was observed in 80 (24.0%) and 454 (47.9%) patients in the ICH and no-ICH groups, respectively, and the adjusted OR was 0.3 (95% confidence interval [CI] = 0.2–0.5, <i>p</i> &#x3c; 0.0001). Incidence of mortality within 90 days was not significantly different between the groups (adjusted OR 1.2; 95% CI: 0.7–1.9, <i>p</i> = 0.5). SICH was observed in 36 (10.8%) of 333 patients with ICH, and the good outcomes were 8.3 and 25.9% in patients with SICH and asymptomatic ICH (AICH), respectively (<i>p</i> = 0.02). Mortality at 90 days was 30.6 and 7.1% in patients with SICH and AICH, respectively (<i>p</i> &#x3c; 0.0001). <b><i>Conclusions:</i></b> The functional outcomes at 90 days were significantly worse in patients who developed ICH after receiving EVT for acute LVO, but the mortality was generally similar.

scholarly journals Comparing the Prognostic Impact of Age and Baseline National Institutes of Health Stroke Scale in Acute Stroke due to Large Vessel Occlusion

Stroke ◽  
2021 ◽  
Author(s):  
Johanna Maria Ospel ◽  
Scott Brown ◽  
Manon Kappelhof ◽  
Wim van Zwam ◽  
Tudor Jovin ◽  
...  
Keyword(s):  
Effect Size ◽  
Interquartile Range ◽  
National Institutes Of Health ◽  
Large Vessel ◽  
Prognostic Impact ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
The Impact ◽  
Size Estimates

Background and Purpose: Little is known about the combined effect of age and National Institutes of Health Stroke Scale (NIHSS) in endovascular treatment (EVT) for acute ischemic stroke due to large vessel occlusion, and it is not clear how the effects of baseline age and NIHSS on outcome compare to each other. The previously described Stroke Prognostication Using Age and NIHSS (SPAN) index adds up NIHSS and age to a 1:1 combined prognostic index. We added a weighting factor to the NIHSS/age SPAN index to compare the relative prognostic impact of NIHSS and age and assessed EVT effect based on weighted age and NIHSS. Methods: We performed adjusted logistic regression with good outcome (90-day modified Rankin Scale score 0–2) as primary outcome. From this model, the coefficients for NIHSS and age were obtained. The ratio between the NIHSS and age coefficients was calculated to determine a weighted SPAN index. We obtained adjusted effect size estimates for EVT in patient subgroups defined by weighted SPAN increments of 3, to evaluate potential changes in treatment effect. Results: We included 1750/1766 patients from the HERMES collaboration (Highly Effective Reperfusion Using Multiple Endovascular Devices) with available age and NIHSS data. Median NIHSS was 17 (interquartile range, 13–21), and median age was 68 (interquartile range, 57–76). Good outcome was achieved by 682/1743 (39%) patients. The NIHSS/age effect coefficient ratio was ([−0.0032]/[−0.111])=3.4, which was rounded to 3, resulting in a weighted SPAN index defined as ([3×NIHSS]+age). Cumulative EVT effect size estimates across weighted SPAN subgroups consistently favored EVT, with a number needed to treat ranging from 5.3 to 8.7. Conclusions: The impact on chance of good outcome of a 1-point increase in NIHSS roughly corresponded to a 3-year increase in patient age. EVT was beneficial across all weighted age/NIHSS subgroups.

Abstract TP74: Aspects Scoring Applied to CTA Source Images is Predictive of Final Infarct Volume and Good Functional Outcome

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Joseph F Carrera ◽  
Joseph H Donahue ◽  
Prem P Batchala ◽  
Andrew M Southerland ◽  
Bradford B Worrall
Keyword(s):  
Linear Regression ◽  
Functional Outcome ◽  
Infarct Volume ◽  
Univariate Analysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
The Impact

Introduction: CTP and MRI are increasingly used to assess endovascular thrombectomy (EVT) candidacy in large vessel occlusion stroke. Unfortunately, availability of these advanced neuroimaging techniques is not widespread and this can lead to over-triage to EVT-capable centers. Hypothesis: ASPECTS scoring applied to computed tomography angiography source images (CTA-SI) will be predictive of final infarct volume (FIV) and functional outcome. Methods: We reviewed data from consecutive patients undergoing EVT at our institution for anterior circulation occlusion between 01/14 - 01/19. We recorded demographics, comorbidities, NIHSS, treatment time parameters, and outcomes as defined by mRS (0-2 = good outcome). Cerebrovascular images were assessed by outcome-blinded raters and collateral score, TICI score, FIV, and both CT and CTA-SI ASPECTS scores were noted. Patients were grouped by ASPECTS score into low (0-4), intermediate (5-7), and high (8-10) for some analyses. FIV was predicted using a linear regression with NIHSS, good reperfusion (TICI 2b/3), collateral score, CT to groin puncture, CT and CTA-SI ASPECTS as independent variables. After excluding those with baseline mRS≥2, a binary logistic regression was performed including covariates of age, NIHSS, good reperfusion, and diabetes (factors significant at p<0.05 on univariate analysis) to assess the impact of CTA-SI ASPECTS group on outcome. Results: Analysis included 137 patients for FIV and 102 for outcome analysis (35 excluded for baseline mRS≥ 2). Linear regression found CTA-SI ASPECTS (Beta -10.8, p=0.002), collateral score (Beta -42.9, p=0.001) and good reperfusion (Beta 72.605, p=0.000) were independent predictors of FIV. Relative to the low CTA-SI ASPECTS group, the high CTA-SI ASPECTS group was more likely to have good outcome (OR 3.75 [95% CI 1.05-13.3]; p=0.41). CT ASPECTS was not predictive of FIV or good outcome. Outcomes: In those undergoing EVT for anterior circulation occlusion, CTA-SI ASPECTS is predictive of both FIV and functional outcome, while CT ASPECTS predicts neither. CTA-SI ASPECTS holds promise as a lower-cost, more widely available option for triage of patients with large vessel occlusion. Further study is needed comparing CTA-SI ASPECTS to CTP parameters.

Abstract TMP4: Impact of Bridging Therapy With Intravenous Thrombolysis Prior to Mechanical Thrombectomy in Patients With Large Vessel Occlusion- Insights From the STAR Registry

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Sami Al Kasab ◽  
Eyad Almallouhi ◽  
Ali Alawieh ◽  
Christine A Holmstedt ◽  
Reda M Chalhub ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Mechanical Thrombectomy ◽  
Group Versus ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Bridging Therapy ◽  
Vessel Occlusion ◽  
Procedural Time ◽  
The Impact

Introduction: Clinical trials have proven the safety and efficacy of mechanical thrombectomy (MT) with intravenous alteplase (tPA) compared to tPA alone in patients presenting with large vessel occlusion (LVO). The impact of tPA prior to MT on procedural metrics, successful revascularization, symptomatic hemorrhage and long-term functional outcome has not been established from large scale real-world studies. In this study we evaluate the impact of tPA prior to MT on procedural times, immediate and long-term outcomes. Methods: The STAR registry combined prospectively maintained databases of 11 thrombectomy-capable stroke centers in the US, Europe and Asia. Patients who received mechanical thrombectomy with or without intravenous tPA prior to MT were included in these analyses. Baseline characteristics, procedural time, successful revascularization (TICI ≥ 2B), symptomatic intracranial hemorrhage (PH2), and long-term functional outcomes were compared between the two groups. Results: Total of 1869 patients were included in this analysis. Of those, 907 received tPA prior to MT. Baseline features and outcomes are summarized in table 1. There were more white patients in the non-tPA group, and more patients in this group had atrial fibrillation and hyperlipidemia; otherwise there were no differences in baseline features between the two groups. Median NIHSS on admission was 16 in both groups, median ASPECTS was 9 in the tPA group versus 8 in the non-tPA group, p=0.208. Patients in the tPA group had higher rate of successful revascularization, lower number of revascularizations attempts and were more likely to achieve excellent long-term functional outcome. There was no difference in procedural time, rate of symptomatic hemorrhage or length of hospital stay. Conclusion: Bridging therapy with intravenous tPA prior to mechanical thrombectomy may facilitate MT and yield to better long-term functional outcome.

Abstract WP26: Validation of Predictive Scales of Functional Outcome After Endovascular Therapy Using the REVASCAT Data

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Natalia Perez de la Ossa ◽  
Srikant Rangaraju ◽  
Tudor Jovin ◽  
Anoni Dávalos ◽  
Keyword(s):  
Functional Outcome ◽  
Endovascular Therapy ◽  
Predictive Accuracy ◽  
Functional Independence ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
Best Medical Treatment

Introduction: Various scales have been developed to predict long-term clinical outcome after endovascular therapy (EVT) in stroke patients. The objective of this study was to validate and compare five well-validated scales in terms of predictive accuracy for functional independence in a recent endovascular stroke trial (REVASCAT). Hypothesis: We hypothesize that predictive scales (PRE, THRIVE, HIAT2, SPAN-100, FAR) have good-excellent (AUC>0.7) predictive accuracy for good functional outcome and can predict the beneficial effect of EVT demonstrated in randomized clinical trials. Methods: REVASCAT (Randomized Trial of Revascularization with Solitaire-FR Device versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting within Eight Hours of Symptom Onset) enrolled 206 patients who were randomized to receive EVT or best medical treatment. Five scores (PRE-score, THRIVE, HIAT2, SPAN-100 and FAR-score) were retrospectively calculated on patients who received EVT. Receiver-operator characteristics (ROC) for good outcome (mRS 0-2 at 90 days) for each scale were compared. Using the highest predictive scales, the proportion of patients with good outcome by the score categorized in quartiles was analyzed. Results: 103 patients received EVT in the REVASCAT trial (mean age 65.7, median NIHSS 17). Baseline NIHSS, baseline CT-ASPECTS, age and atrial fibrillation, but not previous iv tPA or DM, were associated with good outcome in multivariable analysis. AUC for good outcome was ≥0.70 for FAR (0.74) and PRE (0.70) scores while SPAN-100 (0.67), HIAT2 (0.65) and THRIVE (0.64) had lower AUCs although differences were not statistically significant. The higher the score on the PRE and FAR scores, the lower the proportion of patients with good outcome (PRE-score: 1QT 44.4%, 2QT 24.4%, 3QT 22.2%, 4 QT 8.9%; FAR-score: 1QT 57.8%, 2QT 22.2%, 3QT 6.7%, 4QT 3.3%). Benefit of EVT accordingly to the score on the different scales will be also presented. Conclusions: Of the 5 stroke scales, FAR and PRE had better predictive accuracy for functional independence after EVT. These tools may facilitate decision making for EVT in anterior circulation large vessel occlusion stroke.

scholarly journals Impact of the COVID-19-pandemic on thrombectomy services in Germany

2020 ◽  
Vol 2 (1) ◽  
Author(s):  
Steffen Tiedt ◽  
◽  
Felix J. Bode ◽  
Timo Uphaus ◽  
Anna Alegiani ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Functional Outcomes ◽  
Large Cohort ◽  
Large Vessel ◽  
Time Interval ◽  
Large Vessel Occlusion ◽  
Time Intervals ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Interhospital Transfer

Abstract Background The Coronavirus Disease 2019 (COVID-19) pandemic may have altered emergency workflows established to optimize the outcome of patients with large-vessel occlusion (LVO) stroke. Aims We here analyzed workflow time intervals and functional outcomes of LVO patients treated with endovascular thrombectomy (ET) during the COVID-19 pandemic in Germany. Methods We compared the frequency, pre- and intrahospital workflow time intervals, rates of reperfusion, and functional outcome of patients admitted from March 1st to May 31st 2020 with patients admitted during the same time interval in 2019 to 12 university and municipal hospitals across Germany (N = 795). Results The number of LVO patients treated with ET between March to May 2020 was similar when compared to the same interval in 2019. Direct-to-center patients and patients admitted through interhospital transfer in 2020 showed similar pre- and intrahospital workflow time intervals compared to patients admitted in 2019, except for a longer door-to-groin time in patients admitted through interhospital transfer in 2020 (47 min vs 38 min, p = 0.005). Rates of reperfusion were not significantly different between 2020 and 2019. Functional outcome at discharge of LVO patients treated in 2020 was not significantly different compared to patients treated in 2019. Conclusion Pre- and intrahospital workflows, ET efficacy, and functional outcome of LVO patients treated with ET were not affected during the COVID-19 pandemic in our large cohort from centers across Germany.

scholarly journals Impact of onset-to-groin puncture time within three hours on functional outcomes in mechanical thrombectomy for acute large-vessel occlusion

2017 ◽  
Vol 24 (2) ◽  
pp. 162-167 ◽  
Author(s):  
Takahiro Ota ◽  
Yasuhiro Nishiyama ◽  
Satoshi Koizumi ◽  
Tomonari Saito ◽  
Masayuki Ueda ◽  
...  
Keyword(s):  
Scale Score ◽  
Functional Outcomes ◽  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Multivariable Logistic Regression Analysis ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
The Impact

Introduction Endovascular treatment for acute ischemic stroke with acute large-vessel occlusion (ALVO) has established benefits, and rapid treatment is vital for mechanical thrombectomy in ALVO. Time from onset of stroke to groin puncture (OTP) is a practical and useful clinical marker, and OTP should be shortened to obtain the maximum benefit of thrombectomy. Objective The aim of the present study was to assess the impact of early treatment of anterior circulation stroke within three hours after symptom onset and to evaluate the role of OTP in determining outcomes after endovascular therapy. Methods Consecutive patients with acute stroke due to major artery (internal carotid or middle cerebral arteries) occlusion who underwent endovascular recanalization between March 2014 and January 2017 were retrospectively evaluated. Patients were stratified by OTP into three categories: 0–≤3 h, >3–≤6 h, and >6 h. The primary outcome measure was a 90-day modified Rankin scale score of 0–2 (good outcome). Results Data were analyzed from 100 patients (mean age, 76.6 years; mean National Institutes of Health Stroke Scale score, 17). Groin puncture occurred within 0–≤3 h in 51 patients, >3–≤6 h in 28, and >6 h in 21. Median OTP in each group was 126 min (range, 57–168 min), 238 min (range, 186–360 min) and 728 min (range, 365–1492 min), respectively. On multivariable logistic regression analysis, category of OTP represented an independent predictor of patient outcome (adjusted odds ratio, 0.48; 95% confidence interval, 0.25–0.93; p = 0.029). Conclusions OTP is a prehospital and in-hospital workflow-based indicator. In this single-center study, OTP was found to independently affect functional outcomes after endovascular stroke treatment.

Abstract WP3: Predictors and Outcomes of Successful First Pass in Neurothrombectomy- Insights From the STAR Collaboration

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Eyad Almallouhi ◽  
Sami Al Kasab ◽  
Ali Alawieh ◽  
Reda M Chalhoub ◽  
Mohammad Anadani ◽  
...  
Keyword(s):  
Functional Outcomes ◽  
Independent Predictor ◽  
Functional Independence ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
First Pass ◽  
Iv Tpa

Introduction: Shorter procedure time during neurothrombectomy is a strong predictor for good outcomes in stroke patients with large vessel occlusion. We sought to assess the predictors and outcomes of successful first pass (SFP) using multi-center investigator-initiated database. Methods: Prospectively collected neurothrombectomy data from 11 thrombectomy-capable stroke centers was combined in the Stroke Thrombectomy and Aneurysm Registry (STAR). SFP was defined by achieving modified Thrombolysis in Cerebral Infarction (mTICI) score≥2b with a single thrombectomy device pass. We compared the baseline characteristics, procedural metrics, rate of symptomatic intracranial hemorrhage (sICH), and long-term functional outcomes between SFP and non-SFP patients. A multivariate logistic regression analysis was used to assess the predictors of SFP and evaluate whether SFP was an independent predictor for good long-term functional outcomes (90-day mRS≤2). Results: A total of 733 SFP patients and 1134 non-SFP patients were included in this analysis. SFP patients were older (73 vs. 70, P=0.001), had higher Alberta Stroke Program Early CT (ASPECT) score on presentation (9 vs. 8, P=0.002). The use of Solumbra technique was an independent predictor of SFP (OR 1.2, 95% CI 1.1-1.4, P=0.004) after controlling for age, sex, location of occlusion, National Institute of Health stroke scale (NIHSS) on presentation, intravenous alteplase (IV-tPA), and onset to groin (OTG) time. SFP was an independent predictor for good long-term functional outcomes (OR1.6, 95% CI 1.1-2.3, P=0.008) after controlling for age, sex, location of occlusion, NIHSS on presentation, OTG time, IV-tPA, procedure technique, and procedure duration. Conclusion: SFP lead to higher rates of functional independence in stroke patients with large vessel occlusion. These records reiterate the importance of SFP as a benchmark measure for stroke thrombectomy devices.

scholarly journals Acute and Chronic Kidney Dysfunction and Outcome After Stroke Thrombectomy

2021 ◽  
Author(s):  
Simon Fandler-Höfler ◽  
Balazs Odler ◽  
Markus Kneihsl ◽  
Gerit Wünsch ◽  
Melanie Haidegger ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Mechanical Thrombectomy ◽  
Multivariable Analysis ◽  
Unfavorable Outcome ◽  
Large Vessel ◽  
Study Cohort ◽  
Large Vessel Occlusion ◽  
Kidney Dysfunction ◽  
Vessel Occlusion ◽  
The Impact

AbstractData on the impact of kidney dysfunction on outcome in patients with stroke due to large vessel occlusion are scarce. The few available studies are limited by only considering single kidney parameters measured at one time point. We thus investigated the influence of both chronic kidney disease (CKD) and acute kidney injury (AKI) on outcome after mechanical thrombectomy. We included consecutive patients with anterior circulation large vessel occlusion stroke receiving mechanical thrombectomy at our center over an 8-year period. We extracted clinical data from a prospective registry and investigated kidney serum parameters at admission, the following day and throughout hospital stay. CKD and AKI were defined according to established nephrological criteria. Unfavorable outcome was defined as scores of 3–6 on the modified Rankin Scale 3 months post-stroke. Among 465 patients, 31.8% had an impaired estimated glomerular filtration rate (eGFR) at admission (< 60 ml/min/1.73 m2). Impaired admission eGFR was related to unfavorable outcome in univariable analysis (p = 0.003), but not after multivariable adjustment (p = 0.96). Patients frequently met AKI criteria at admission (24.5%), which was associated with unfavorable outcome in a multivariable model (OR 3.03, 95% CI 1.73–5.30, p < 0.001). Moreover, patients who developed AKI during hospital stay also had a worse outcome (p = 0.002 in multivariable analysis). While CKD was not associated with 3-month outcome, we identified AKI either at admission or throughout the hospital stay as an independent predictor of unfavorable prognosis in this study cohort. This finding warrants further investigation of kidney–brain crosstalk in the setting of acute stroke.

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