Hospital management of major stroke types in Chinese adults: a population-based study of 20 000 hospitalised stroke cases

ObjectivesTo compare hospital treatments for major stroke types in Chinese adults by stroke pathological types, sex, age, calendar year, hospital tier, region and other factors.DesignCross-sectional analysis of medical records retrieved from 20 229 stroke cases in the China Kadoorie Biobank.SettingTen diverse areas (five urban, five rural) in China.ParticipantsFirst-incident stroke cases who were recruited during an 11-year follow-up of 0.5M participants in the China Kadoorie Biobank.MethodsElectronic copies of medical records of stroke cases were retrieved for clinical adjudication by local neurologists. Stroke cases were classified as ischaemic stroke (IS) (including lacunar infarction (LACI) and non-LACI (non-LACI)), intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH) and unspecified stroke types.ResultsAmong 20 299 first-ever stroke cases, 17 306 (85%) had IS, 7123 had non-LACI, 6690 had LACI, 3493 had silent LACI, 2623 (13%) had ICH and 370 (2%) had SAH. Among IS cases, antiplatelet treatment was used by 64% (65% non-LACI, 66% LACI, 56% silent LACI), lipid-lowering by 50% (52% non-LACI, 53% LACI, 43% silent LACI) and blood pressure-lowering by ~42% of all IS types, with positive trends in the use of these treatments by calendar year and hospital tier. Among ICH cases, 53% used blood pressure-lowering and 10% used lipid-lowering treatments, respectively. In contrast, traditional Chinese medicines (TCMs) were used by 59% of IS (50% non-LACI, 62% LACI, 74% silent LACI), 38% of ICH and 30% of SAH cases, with positive trends by calendar year and by hospital tier.ConclusionsAmong IS cases, use of antiplatelet and lipid-lowering medications increased in recent years, but use of TCM still exceeded use of blood pressure-lowering treatment. In contrast, blood pressure-lowering treatment was widely used for ICH, but only half of all ICH cases used blood pressure-lowering treatment.

The ARTISSE intrasaccular device for intracranial aneurysm treatment: short-term, mid-term and long-term clinical and angiographic results

BackgroundThe concept of intra-aneurysmal flow disruption has emerged as a new paradigm for the treatment of primarily bifurcation aneurysms. The purpose of this study was to determine the clinical and angiographic outcomes of patients treated with the new ARTISSE intrasaccular device (ISD).MethodsSelected patients with bifurcation aneurysms that matched the indications of the ARTISSE ISD defined by the manufacturer were treated in a single center. Clinical and angiographic follow-up was conducted at 6 and 36 months. Aneurysm occlusion was assessed using the Raymond–Roy classification scale.ResultsNine subjects with nine unruptured bifurcation aneurysms were enrolled. Mean aneurysm size was 7.2±1.2 mm (range 5.5–9.7 mm). An adequate aneurysm occlusion (defined as a complete occlusion or a neck remnant) was achieved in 6/9 patients (66.7%) at 6 months and 4/7 patients (57.1%) at 36 months follow-up. Two of the nine subjects experienced a major stroke (22.2%), including one on postoperative day 1 due to a procedure-related parent vessel occlusion and subsequent ischemic stroke. The other major stroke occurred within the 36-month follow-up period during treatment of a separate aneurysm with coils, leading to perforation with hemorrhagic stroke causing a permanent neurological deficit.ConclusionThe ARTISSE ISD was successfully deployed in all nine cases. There were, however, several procedure-related complications and results in terms of angiographic aneurysm occlusion were modest.

Multi-centric European post-market follow-up study of the Neuroform Atlas Stent System: primary results

BackgroundFew prospective series have described the safety and effectiveness of the Neuroform Atlas Stent System. We aimed to investigate the efficacy and safety of the device in patients treated for unruptured aneurysm.MethodsATLAS EU PMCF is a consecutive, prospective, multicentric study that included patients with unruptured saccular aneurysm of all sizes. Follow-up visits were scheduled at 3–6 months and 12–16 months with digital subtraction angiography (DSA) or MRI imaging follow-up as per the site standard of care. The primary efficacy endpoint was adequate aneurysm occlusion (Raymond Roy occlusion grade I and II) on 12 month angiography. The primary safety endpoint was any major stroke or ipsilateral stroke or neurological death within 12 months.ResultsOf the 106 patients consented, 105 were treated with at least one Neuroform Atlas stent. There was a failed implantation attempt in 1 patient, 85 patients received lateral stenting, and 19 patients received Y-stenting. Mean aneurysm neck size was 4.2 mm (range 1.9–33 mm). Adequate occlusion was observed in 95.1% immediately after the procedure and in 98.9% of cases at 1 year DSA follow-up. Overall, 1.0% (1/102; 95% CI 0.0% to 5.3%) of patients experienced a primary safety endpoint of major stroke. Three minor strokes resulted in a modified Rankin Scale score of 2.ConclusionsIn this multicentric, prospective study, stent-assisted coiling of medium size unruptured aneurysms with the Neuroform Atlas stent resulted in a favorable rate of satisfactory occlusion. In our findings, the use of the Y-stenting technique was associated with increased rates of procedural complications.Clinical trial registrationhttps://clinicaltrials.gov/ct2/show/NCT02783339.

Comparing the impact of an icon array versus a bar graph on preference and understanding of risk information: Results from an online, randomized study

Background Few studies have examined the best way to convey the probability of serious events occurring in the future (i.e., risk of stroke or death) to persons with low numeracy or graph literacy proficiency. To address this gap, we developed and user-tested a bar graph and compared it to icon arrays to assess its impact on understanding and preference for viewing risk information. Objectives To determine the: (i) formats’ impact on participants’ understanding of risk information; (ii) formats’ impact on understanding and format preference across numeracy and graph literacy subgroups; (iii) rationale supporting participants’ preference for each graphical display format. Methods An online sample (evenly made up of participants with high and low objective numeracy and graph literacy) was randomized to view either the icon array or the bar graph. Each format conveyed the risk of major stroke and death five years after choosing surgery, a stent, or medication to treat carotid artery stenosis. Participants answered questions to assess their understanding of the risk information. Lastly, both formats were presented in parallel, and participants were asked to identify their preferred format to view risk information and explain their preference. Results Of the 407 participants, 197 were assigned the icon array and 210 the bar graph. Understanding of risk information and format preference did not differ significantly between the two trial arms, irrespective of numeracy and graph literacy proficiency. High numeracy and graph literacy proficiency was associated with high understanding (p<0.01) and a preference for the bar graph (p = 0.01). Conclusion We found no evidence to demonstrate the superiority of one format over another on understanding. The majority of participants preferred viewing the risk information using the bar graph format.

Five-Year Clinical and Quality of Life Outcomes From the CoreValve US Pivotal Extreme Risk Trial

Background: Older adults with comorbidities who are at extreme risk for surgical aortic valve replacement may be appropriate candidates for transcatheter aortic valve replacement (TAVR). We present the 5-year clinical, echocardiographic, and health status outcomes of such patients treated with CoreValve self-expanding supra-annular TAVR. Methods: The CoreValve US Extreme Risk Pivotal Trial was a prospective, nonrandomized, single-arm clinical trial of TAVR at 41 sites in the United States. The primary outcome was all-cause mortality or major stroke. Secondary outcomes included echocardiographic parameters and patient-reported health status, assessed with the Kansas City Cardiomyopathy Questionnaire. Results: Between February 2011 and August 2012, 639 patients with severe aortic stenosis at extreme surgical risk underwent attempted TAVR (mean age 82.8±8.4 years, 53% women, mean Society of Thoracic Surgeons Predicted Risk of Mortality 10.4±5.6%, 77% iliofemoral access). The 5-year Kaplan-Meier rate of death or major stroke was 72.6% ([95% CI, 68.4%–76.7%]; death 71.6%, major stroke 11.5%), with no significant differences according to access site. Among patients who survived 5 years, mean transvalvular gradient was 7.5±5.9 mm Hg, and 3.1% had moderate or severe aortic regurgitation. Health status measures improved significantly by 1 month after TAVR through 1 year (mean change in Kansas City Cardiomyopathy Questionnaire–Overall Summary score 24.8 points [95% CI, 22.4–27.2]). Beyond 1 year, the Kansas City Cardiomyopathy Questionnaire–Overall Summary score decreased gradually but remained significantly improved from pre-TAVR through 5 years of follow-up among surviving patients (mean change from baseline, 14.3 points [95% CI, 10.7–17.9]). Conclusions: Patients with severe aortic stenosis at extreme surgical risk who are treated with self-expanding supra-annular TAVR have high 5-year mortality. However, the short-term benefits of TAVR in terms of valve hemodynamics and quality of life are mostly preserved among surviving patients at 5 years, thereby supporting the continued use of TAVR in these challenging patients. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01240902.

Abstract P604: Incidentally-Discovered Asymptomatic Ischemic Lesions Identified Using Natural Language Processing Are Strong Risk Markers for Future Ischemic Stroke

Background: White matter disease (WMD) and silent brain infarction (SBI) are known to be risk markers for stroke. Nevertheless, the predictive value of these changes when seen incidentally on routinely-obtained neuroimages is unknown. Methods: In this retrospective cohort study, Kaiser Permanente-Southern California health plan enrollees aged ≥ 50 years old with a brain CT or MRI scan between 2009-2019 and without a prior history of ischemic stroke, transient ischemic attack, or dementia were identified. Natural language processing (NLP) was used to identify patients with SBI and WMD on the index neuroimaging report. We used Cox proportional hazards to estimate the risk of future ischemic stroke associated with the presence of SBI and of WMD, controlling for major stroke risk factors. Results: Among 262,875 individuals receiving brain neuroimaging, 13,154 (5.0%) and 78,330 (29.8%) had SBI and WMD, respectively. The Table below summarizes the crude stroke incidence rates. The crude hazard ratio (HR) was 3.40 (95% CI 3.25-3.56) for SBI and 2.63 (95% CI 2.54-2.71) for WMD. In the multivariable model controlling for all major stroke risk factors, the effect of SBI was found to be stronger in younger versus older patients and for MRI- versus CT-discovered lesions. With MRI, the average adjusted HR over time was 2.95 (95% CI 2.53-3.44) for those < age 65 and 2.15 (95% CI 1.91-2.41) for those ≥ age 65. With CT scan, the average adjusted HR over time was 2.48 (95%CI 2.19-2.81) for those < age 65 and 1.81 (95% CI 1.71-1.91) for those ≥ age 65. The adjusted HR associated with a finding of WMD was 1.76 (95% CI 1.69-1.82) and was not modified by age or imaging modality. The effect of SBI decreased gradually over time, while the effect of WMD remained constant. Conclusion: Incidentally-discovered SBI and WMD are common in patients ≥ age 50 and are associated with substantial increases in the risk of subsequent symptomatic stroke. The findings may represent an opportunity for stroke prevention.

Abstract P448: Axial versus Vertical Area of Intracerebral Hemorrhage and Outcome

Background: Intracerebral hemorrhage (ICH) has the highest morbidity and mortality rate of the major stroke subtypes. Volume is a well-established predictor of outcome. Theoretically, ICH should expand more in areas of less resistance. We hypothesize that 1) expansion perpendicular to neural tracts (axially) will be less great than expansion parallel to tracts (vertically) and 2) differing effect on outcome will occur based on axial and vertical areas of hemorrhage. Methods: The Genetic and Environmental Risk Factors of Hemorrhagic Stroke (GERFHS) study is a population-based case-control study. Each case of ICH within the 5 county region of Greater Cincinnati was evaluated for volume of hemorrhage with a subset completing 3 month telephone follow-up to obtain data including modified Rankin Scale (mRS). Baseline variables were assessed for poor outcome, defined as mRS greater than or equal to 3 at 90 days. Results: From July 2009 to December 2012, 1205 cases of ICH were identified, of which 304 had 3-month follow up. The table presents univariate association with outcome. More than 86% of hemorrhages had greater vertical area than axial area. On multivariable analysis controlling for ICH score variables, vertical area showed a trend toward worse outcome (OR 1.09, p= 0.06) vs axial area (OR 0.97, p=0.69) which was not found to have a significant effect on outcome independent of total volume. Conclusion: Most patients have greater vertical expansion of ICH than axial expansion. This pattern of hemorrhage growth is consistent with neural tracts having less resistance vertically. If the greater impact on outcome is confirmed, improved outcome and trial inclusion criteria may be determined.

Abstract P396: Hospital Management of Major Stroke Types in Urban and Rural China: Findings From a 11-Year Community-Based Studies Involving >20,000 Hospitalized Stroke Cases

Background: Little is known about the contemporary use of hospital treatments for major stroke pathological types in urban and rural areas of China. Methods: The China Kadoorie Biobank recruited >0.5 million adults (mean age 51 years, 59% women) during 2004-08 from ten (five urban, five rural) diverse areas in China. In-hospital medical records were retrieved from 20,229 participants (n=261 hospitals) hospitalised with a first-ever incident stroke over an 11-year follow-up period. Details of hospital management of stroke cases were analysed by sex, age of stroke onset, calendar year, hospital tier, region and other factors. Results: Among the 20,299 first-ever stroke cases, 17,306 (85%) had ischaemic stroke (IS; 7,123 non-lacunar, 6,690 lacunar and 3,493 silent lacunar), 2,623 (13%) had intracerebral haemorrhage (ICH), and 370 (2%) had subarachnoid haemorrhage (SAH). Among IS cases, anti-platelet treatment was used by 64% (65% non-lacunar, 66% lacunar, 56% silent lacunar), lipid-lowering by 50% (52% non-lacunar, 53% lacunar, 43% silent lacunar), blood pressure-lowering by about 42% of all IS subtypes, along with traditional Chinese medicines (TCM) by 59% (50% non-lacunar, 62% lacunar, 74% silent lacunar), with positive trends in use of these treatments by calendar year (Figure 1A), but inverse trends by hospital tier except TCM (Figure 1B). Approximately half of ICH (52.6%) or SAH (50.5%) cases received blood pressure-lowering medication, which did not vary significantly by area. A small proportion of cases with SAH had surgery to insert a coil (7.0%) or clip on aneurysm (5.7%). Interpretation: Among IS cases, use of antiplatelet, lipid-lowering and TCM increased in recent years and exceeded use of blood pressure-lowering treatment. In contrast, about half of all ICH and SAH cases used blood pressure-lowering treatments and there is significant under-use of surgery for SAH cases.

Safety and Efficacy of Tirofiban for Acute Ischemic Stroke Patients With Large Artery Atherosclerosis Stroke Etiology Undergoing Endovascular Therapy

Objective: To investigate the safety and efficacy of tirofiban in acute ischemic stroke (AIS) patients with large artery atherosclerosis (LAA) stroke etiology receiving endovascular therapy (EVT).Methods: In this multi-center prospective study, patients who were considered to have an indication received a low dose intra-arterial bolus (0.25–1 mg) of tirofiban. The safety and efficacy outcomes at 90-day follow-ups included symptomatic intracranial hemorrhage (sICH), recanalization rate, functional outcome, and mortality.Results: Among the 649 AIS patients with LAA, those in the tirofiban group (n = 244) showed higher systolic blood pressure (BP) and NIHSS score on admission, puncture-to-recanalization time, lower frequency of intravenous thrombolysis and intra-arterial thrombolysis, higher frequency of antiplatelet, heparinization, mechanical stent retrieval, aspiration, balloon angioplasty, and more retrieval times compared with those in the non-tirofiban group (n = 405) (all P &lt; 0.05). Tirofiban was found to be associated with superior clinical outcomes in anterior circulation stroke and major stroke patients [adjusted odds ratio (OR) = 2.163, 95% confidence interval (CI) = 1.130–4.140, P = 0.02 and adjusted OR = 2.361, 95% CI = 1.326–4.202, P = 0.004, respectively] and a lower risk of mortality at 90-day follow-ups (adjusted OR = 0.159, 95% CI = 0.042–0.599, P = 0.007 and adjusted OR = 0.252, 95% CI = 0.103–0.621, P = 0.003, respectively). There was no significant difference in sICH between the two groups.Conclusions: Tirofiban in AIS patients with LAA undergoing EVT is safe and may benefit the functional outcomes in anterior circulation and major stroke patients and showed a trend for reduced mortality.