scholarly journals Outcomes of Endovascular Therapy in Patients With Prestroke Mobility Impairment

Stroke ◽  
2021 ◽  
Author(s):  
Rachel Beekman ◽  
Jie-Lena Sun ◽  
Brooke Alhanti ◽  
Lee H. Schwamm ◽  
Eric E. Smith ◽  
...  

Background and Purpose: Patients with prestroke mobility impairment (PSMI) were excluded from endovascular clinical trials. There are limited data regarding safety and outcomes of endovascular thrombectomy in this population. We used a large, national data set (Get With The Guidelines–Stroke) to evaluate the safety and outcomes of endovascular thrombectomy in patients with PSMI. Methods: We included patients who underwent endovascular thrombectomy in the Get With The Guidelines–Stroke registry between 2015 and 2019. PSMI was defined as the inability to ambulate independently. Generalized estimating equations for logistic regression models were used to evaluate the association between PSMI and outcomes. Results: Of 56 762 patients treated with endovascular thrombectomy, 2919 (5.14%) had PSMI. PSMI was not associated with symptomatic intracranial hemorrhage (6.0% versus 5.4%; P =0.979). In-hospital death or discharge to hospice occurred in 32.3% of patients with PSMI versus 17.5% without PSMI (adjusted odds ratio, 1.45 [1.32–1.58]). Conclusions: While procedural adverse outcomes were no higher in patients with PSMI, further study is necessary to determine clinical benefit in this population.

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Rachel Beekman ◽  
Jie-Lena Sun ◽  
Brooke Alhanti ◽  
Lee H Schwamm ◽  
Eric Smith ◽  
...  

Background and Purpose: Patients with pre-stroke mobility impairment were excluded from endovascular clinical trials. There is limited data regarding safety and outcomes of endovascular thrombectomy (EVT) in this population. We used a large, national dataset (Get With The Guidelines (GWTG)-Stroke) to evaluate the safety and outcomes of EVT in patients with pre-stroke mobility impairment (PSMI). Methods: We included patients who underwent EVT in the GWTG-Stroke registry between 2015 and 2019. PSMI was defined as inability to ambulate independently and poor outcome was defined as in-hospital mortality or discharge to hospice. GEE logistic regression models were used to evaluate the association between PSMI and outcomes. Results: Of 56,762 patients treated with EVT, 2919 (5.14%) had PSMI. Patients with PSMI were older (median 79 [IQR 70-87] vs 70 [59-80], P<0.001), more likely to be female (63.4% vs 49.2%, P<0.001), had more medical comorbidities, presented with a higher NIHSS (19 [12-24] vs 15 [9-21], P<0.001), and were less likely to be treated with tPA (36.8% vs 45.6%, P<0.001). PSMI was not associated with intracranial hemorrhage but was associated with poor outcome (Table 1). Patients with PSMI with poor outcomes were more likely to be older (83 [74-89] vs 77 [68-86], P<0.001) and have a higher presenting NIHSS (21 [16-25] vs 16 [11-22], p<0.001). Forty-nine percent of patients with PSMI with age >80 years and NIHSS >20 had a poor outcome. Conclusions: Amongst patients with PSMI treated with EVT, two thirds survived and one third were discharged to home or to inpatient rehabilitation. Advanced age and increased stroke severity increased the likelihood of poor outcomes. EVT appears safe in patients with PSMI, yet further study of effectiveness in this population is warranted.


Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Jose G Romano ◽  
Eric E Smith ◽  
Li Liang ◽  
Hannah Gardener ◽  
Sara Camp ◽  
...  

Objective: Mild stroke has traditionally been excluded from thrombolytic treatment trials and only few series have reported outcomes after IV rtPA in this group. The objectives of this study are to determine the proportion of mild stroke patients treated with IV rtPA and evaluate complications and short-term outcomes in this population. Methods: We analyzed patients in the Get With The Guidelines-Stroke registry that arrived within 4.5 hours from symptom onset with a mild ischemic stroke defined as a baseline NIHSS ≤5 who received IV rtPA between May 2010 and October 2012. The following outcomes and complications were analyzed: in-hospital mortality, home discharge, independent ambulation, length of stay (LOS), in-hospital death, and symptomatic intracranial hemorrhage (sICH) <36 h. Multivariable analysis was performed for predictors of outcomes and complications. Results: Of 147,917 patients who arrived <4.5 hours, 39,821 were treated with IV rtPA, of whom 8,243 (20.7%) had an NIHSS ≤5. We analyzed 5,910 treated patients with NIHSS ≤5 and complete data. The mean baseline NIHSS was 3.5 (median 4); 98.2% arrived within 3 hours and 78.6% were treated within 3 hours. Outcomes and predictors of worse outcome are described in the table. There was no difference in short-term outcomes amongst those treated at 0-3 vs. 3-4.5 hours. Conclusions: A sizeable minority of ischemic stroke patients treated with IV rtPA have a NIHSS ≤5. sICH occurred at a low rate of 1.8% and about 30% of these patients were unable to return home and could not ambulate independently. Longer-term outcomes are needed to define predictors of poor outcome in this population and which patients may benefit most from treatment.


Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Bijoy K Menon ◽  
Jeffrey L Saver ◽  
Mayank Goyal ◽  
Raul Noguiera ◽  
Shyam Prabhakaran ◽  
...  

Purpose: To determine hospital and patient level characteristics associated with use of endovascular therapy for acute ischemic stroke and to analyze trends in clinical outcome. Methods: Data were from Get With The Guidelines-Stroke hospitals from 4/1/2003 to 6/30/2013. We looked at secular trends in number of hospitals providing endovascular therapy, use of endovascular therapy in these hospitals, and clinical outcomes. We also analyzed hospital and patient characteristics associated with endovascular therapy utilization. Results: Of 1087 hospitals, 454 provided endovascular therapy to at least one patient in the study period. From 2003 to 2012, the proportion of hospitals providing endovascular therapy increased by 1.6%/year (from 12.9% to 28.9%), with a modest drop in 2013 to 23.4%. Use in these hospitals increased from 0.7% to 2% of all ischemic stroke patients (p<0.001) with a modest drop in 2013 to 1.9%. In multivariable analyses, patient outcomes after endovascular therapy improved over time, with reductions in in-hospital mortality (29.6% in 2004 to 16.2% in 2013; p=0.002); and from late 2010, reduction in symptomatic intracranial hemorrhage (ICH) (11% in 2010 to 5% in 2013; p<0.0001) and increased independent ambulation at discharge (24.5% in 2010 to 33% in 2013; p<0.0001) and discharge home (17.7% in 2010 to 26.1% in 2013; p<0.0001) (Attached figure). Hospital characteristics associated with endovascular therapy use included large size, teaching status and urban location while patient characteristics included younger age, EMS transport, absence of prior stroke and white race. Conclusion: Use of endovascular therapy increased modestly in this national registry from 2003 to 2012 and decreased in 2013. Clinical outcomes improved notably from 2010 to 2013, coincident with the introduction of newer thrombectomy devices.


Author(s):  
Jan Philipp Bewersdorf ◽  
Stephanie Prozora ◽  
Nikolai A. Podoltsev ◽  
Rory Michael Shallis ◽  
Scott F Huntington ◽  
...  

Acute promyelocytic leukemia (APL) is associated with a favorable long-term prognosis if appropriate treatment is initiated promptly. Outcomes in clinical trials and population-based registries vary; potential explanations include a delay in treatment and lower adherence to guideline-recommended therapy in real-world practice. We used the Vizient Clinical Data Base (CDB) to describe demographics, baseline clinical characteristics, and treatment patterns in newly diagnosed APL patients during the study period of April 2017 - March 2020. Baseline white blood cell count (WBC) was used to assign risk status and assess treatment concordance with National Comprehensive Cancer Network guidelines. Logistic regression models examined adjusted associations between patient, hospital, disease characteristics, and adverse outcomes (in-hospital death or discharge to hospice). Among 1,464 APL patients, 205 (14.0%) experienced an adverse outcome. A substantial subset (20.6%) of patients did not receive guideline-concordant regimens. Odds of adverse outcomes increased with failure to receive guideline-concordant treatment (OR: 2.31 [95% CI: 1.43 - 3.75]; p=0.001), high-risk disease (OR: 2.48 [1.53 - 4.00]; p&lt;0.001) and increasing age (≥60 years: OR: 11.13 [95% CI: 4.55 - 27.22]; p&lt;0.001). Higher hospital AML patient volume was associated with lower odds of adverse outcome (OR: 0.44 [0.20 - 0.99] for ≤ 50 vs. &gt;200 AML patients/year; p=0.046). In conclusion, in this large database analysis, 14.0% of newly diagnosed APL patients died or were discharged to hospice. A substantial proportion of patients did not receive guideline-concordant therapy, potentially contributing to adverse outcomes.


2021 ◽  
Vol 23 (3) ◽  
pp. 388-400
Author(s):  
Marius Matusevicius ◽  
Charith Cooray ◽  
Viiu-Marika Rand ◽  
Ana Paiva Nunes ◽  
Tiago Moreira ◽  
...  

Background and Purpose The influence of stroke etiology on outcomes after endovascular thrombectomy (EVT) is not well understood. We aimed to investigate whether stroke etiology subgrouped as large artery atherosclerosis (LAA) and cardiac embolism (CE) influences outcomes in large artery occlusion (LAO) treated by EVT.Methods We included EVT treated LAO stroke patients registered in the Safe Implementation of Treatment in Stroke (SITS) thrombectomy register between January 1, 2014 and September 3, 2019. Primary outcome was successful reperfusion (modified Treatment in Cerebral Infarction 2b-3). Secondary outcomes were symptomatic intracranial hemorrhage (SICH), 3-month functional independence (modified Ranking Scale 0–2) and death. Multivariable logistic regression models were used for comparisons. In addition, a meta-analysis of aggregate data from the current literature was conducted (PROSPERO, ID 167447).Results Of 7,543 patients, 1,903 (25.2%) had LAA, 3,214 (42.6%) CE, and 2,426 (32.2%) unknown, other, or multiple etiologies. LAA patients were younger (66 vs. 74, P<0.001) and had lower National Institutes of Health Stroke Scale score at baseline (15 vs. 16, P<0.001) than CE patients. Multivariable analyses showed that LAA patients had lower odds of successful reperfusion (odds ratio [OR], 0.70; 95% confidence interval [CI], 0.57 to 0.86) and functional independence (OR, 0.74; 95% CI, 0.63 to 0.85), higher risk of death (OR, 1.44; 95% CI, 1.21 to 1.71), but no difference in SICH (OR, 1.09; 95% CI, 0.71 to 1.66) compared to CE patients. The systematic review found 25 studies matching the criteria. The meta-analysis did not find any difference between etiologies. Conclusions From the SITS thrombectomy register, we observed a lower chance of reperfusion and worse outcomes after thrombectomy in patients with LAA compared to CE etiology, despite more favorable baseline characteristics. In contrast, the meta-analysis did not find any difference between etiologies with aggregate data.


Neurology ◽  
2019 ◽  
Vol 92 (24) ◽  
pp. e2784-e2792 ◽  
Author(s):  
Jodi A. Dodds ◽  
Ying Xian ◽  
Shubin Sheng ◽  
Gregg C. Fonarow ◽  
Deepak L. Bhatt ◽  
...  

ObjectiveTo determine whether young adults (≤40 years old) with acute ischemic stroke are less likely to receive IV tissue plasminogen activator (tPA) and more likely to have longer times to brain imaging and treatment.MethodsWe analyzed data from the Get With The Guidelines–Stroke registry for patients with acute ischemic stroke hospitalized between January 2009 and September 2015. We used multivariable models with generalized estimating equations to evaluate tPA treatment and outcomes between younger (age 18–40 years) and older (age >40 years) patients with acute ischemic stroke.ResultsOf 1,320,965 patients with acute ischemic stroke admitted to 1,983 hospitals, 2.3% (30,448) were 18 to 40 years of age. Among these patients, 12.5% received tPA vs 8.8% of those >40 years of age (adjusted odds ratio [aOR] 1.63, 95% confidence interval [CI] 1.56–1.71). However, younger patients were less likely to receive brain imaging within 25 minutes (62.5% vs 71.5%, aOR 0.78, 95% CI 0.73–0.84) and to be treated with tPA within 60 minutes of hospital arrival (37.0% vs 42.8%, aOR 0.74, 95% CI 0.68–0.79). Compared to older patients, younger patients treated with tPA had a lower symptomatic intracranial hemorrhage rate (1.7% vs 4.5%, aOR 0.55, 95% CI 0.42–0.72) and lower in-hospital mortality (2.0% vs 4.3%, aOR 0.65, 95% CI 0.52–0.81).ConclusionsIn contrast to our hypothesis, younger patients with acute ischemic stroke were more likely to be treated with tPA than older patients, but they were more likely to experience delay in evaluation and treatment. Compared with older patients, younger patients had better outcomes, including fewer intracranial hemorrhages.


2020 ◽  
Author(s):  
Fatih Seker ◽  
Susanne Bonekamp ◽  
Susanne Rode ◽  
Sonja Hyrenbach ◽  
Martin Bendszus ◽  
...  

Abstract Purpose It is unclear whether stroke patients undergoing endovascular thrombectomy (EVT) should receive bridging intravenous thrombolysis (IVT), if eligible. This study aims at analyzing the impact of bridging IVT on short-term clinical outcome. Methods In a prospective regional stroke registry, all stroke patients with premorbid modified Rankin Scale (mRS) score of 0–2 who were admitted within 4.5 h after onset and treated with EVT were analyzed retrospectively. Patients receiving “IVT prior to EVT” (IVEVT) were compared to those undergoing “EVT only” regarding the ratio of good outcome, discharge mRS, mRS shift, hospital mortality, and occurrence of symptomatic intracranial hemorrhage. Results In total, 2022 patients were included, 816 patients (40.4%) achieved good clinical outcome; 1293 patients (63.9%) received bridging IVT. There was no significant difference between both groups regarding the ratio of good outcome (IVEVT 41.4% vs. EVT 38.5%, P = 0.231), discharge mRS (median, IVEVT 3 vs. EVT 3, P = 0.178), mRS shift (median, IVEVT 3 vs. EVT 3, P = 0.960), and hospital mortality (IVEVT 19.3% vs. EVT 19.5%, P = 0.984). Bridging IVT was not a predictor of outcome (adjusted OR 1.00, 95% CI 0.79–1.26, P = 0.979). However, it was an independent predictor of symptomatic intracranial hemorrhage (adjusted OR 1.79, 95% CI 1.21–2.72, P = 0.005). Conclusions The results of the present study suggest that bridging IVT does not seem to improve short-term clinical outcome of patients undergoing EVT. Nonetheless, there might be a subgroup of patients that benefits from IVT. This needs to be addressed in randomized controlled trials.


Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Lisa Leffert ◽  
Caitlin Clancy ◽  
Brian Bateman ◽  
Margueritte Cox ◽  
Phillip Schulte ◽  
...  

Background: Subarachnoid hemorrhage (SAH) accounts for up to 4.1% of all pregnancy-related in-hospital deaths, but is less often aneurysmal and is associated with better short term outcomes than in non-pregnant patients. We sought to describe the risk factors, management and outcomes of pregnant vs. non-pregnant patients with SAH in the Get With The Guidelines (GWTG) Stroke Registry. Methods: Using medical history or ICD-9 codes, we identified 152 pregnant and 5745 non-pregnant SAH female patients aged 18-44 with SAH in GWTG from 2008-2013. Differences in characteristics were compared by Chi-square tests for categorical and Wilcoxon Rank-Sum tests for continuous variables. Stratified logistic regression assessed the effect of pregnancy on outcomes conditional on age and adjusted for patient and hospital characteristics. Results: Pregnant SAH patients were younger, more often black and insured with Medicaid. They had higher initial blood pressure (BP) and were less likely to report prior hypertension. Arrival delays from stroke onset were common in both groups (median 340 vs. 277 min), but pregnant SAH patients were more often already hospitalized at stroke onset (16% vs. 10%). Fewer pregnant vs. non-pregnant SAH patients had initial neurologic exam findings recorded (Table). Pregnant SAH patients had lower in-hospital death than non-pregnant patients (aOR 0.17, 95% CI 0.06-0.45) and were more likely at discharge to ambulate independently (aOR 2.40, 95% CI 1.56-3.69) and return home (aOR 2.60, 95% CI 1.67-4.06). Conclusions: Several differences exist between pregnant and non-pregnant women with SAH. Many present with BP well below the threshold for hypertensive disorders of pregnancy, making prompt recognition and prevention of brain hemorrhage challenging. Overall, pregnancy-related SAH is associated with less morbidity and mortality than non-pregnancy related disease.


Author(s):  
Dacheng Liu ◽  
Ximing Nie ◽  
Yuesong Pan ◽  
Hongyi Yan ◽  
Yuehua Pu ◽  
...  

Background To investigate whether collateral status could modify the associations between post‐thrombectomy blood pressure (BP) measures and outcomes. Methods and Results Patients with anterior‐circulation large‐vessel‐occlusion successfully recanalized in a multicenter endovascular thrombectomy registry were enrolled. Pretreatment collateral status was graded and dichotomized (good/poor) in angiography. Maximum, minimum, and mean systolic BP (SBP) and BP variability (assessed by the SD, coefficient of variation) during the initial 24 hours after endovascular thrombectomy were obtained. The primary outcome was unfavorable 90‐day outcome (modified Rankin Scale score 3–6). Secondary outcomes included symptomatic intracranial hemorrhage and 90‐day mortality. Adjusted odds ratios (aOR) of BP parameters over the outcomes were obtained in all patients and in patients with good/poor collaterals. Among 596 patients (mean age 66 years; 59.9% males), 302 (50.7%) patients had unfavorable 90‐day outcome. In multivariable analyses, higher mean SBP (aOR, 1.59 per 10 mm Hg increment; 95% CI, 1.26–2.02; P <0.001), mean SBP >140 mm Hg (versus ≤120 mm Hg; aOR, 4.27; 95% CI, 1.66–10.97; P =0.002), and higher SBP SD (aOR, 1.08 per 1‐SD increment; 95% CI, 1.01–1.16; P =0.02) were respectively associated with unfavorable 90‐day outcome in patients with poor collateral but not in those with good collateral. A marginal interaction between SBP coefficient of variation tertiles and collaterals on 90‐day functional outcome ( P for interaction, 0.09) was observed. A significant interaction between SBP coefficient of variation tertiles and collaterals on 90‐day mortality ( P for interaction, 0.03) was observed. Conclusions Higher postprocedural BP is associated with 90‐day unfavorable outcomes after successful endovascular thrombectomy in patients with poor collateral. Registration URL: https://www.chictr.org.cn ; Unique identifier: ChiCTR1900022154.


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