Long term Post-Stroke Functional Outcomes: a comparison of diabetics and non-diabetics

Introduction: Diabetes mellitus (DM) is known to influence outcomes in the short-term following stroke. However, the impact of DM on long-term functional outcomes after stroke is unclear. We compared functional outcomes periodically over 7 years between diabetic and non-diabetic ischemic stroke patients and investigated the impact of DM on the long-term trajectory of post-stroke functional outcomes. We also studied the influence of age on the diabetes-functional outcome association. Methods: This is a longitudinal observational cohort study of 802 acute ischemic stroke patients admitted to the Singapore General Hospital from 2005 to 2007. Functional outcomes were assessed using the modified Rankin Scale (mRS) with poor functional outcome defined as mRS≥3. Follow-up data was determined at 6 months and at median follow-up durations of 29 and 86 months. Results: Among the 802 ischemic stroke patients studied (mean age 64 ± 12 years, male 63%), 42% had DM. In regression analyses adjusting for covariates, diabetic patients were more likely to have poor functional outcomes at 6 months (OR=2.12, 95% CI: 1.23–3.67) and at median follow-up durations of 29 months (OR=1.96, 95% CI: 1.37–2.81) and 86 months (OR=2.27, 95% CI: 1.58–3.25). In addition, age modulated the effect of DM, with younger stroke patients (≤65 years) more likely to have long term poor functional outcome at the 29-month (p=0.0179) and 86-month (p=0.0144) time points. Conclusions: DM was associated with poor functional outcomes following ischemic stroke in the long term with the effect remaining consistent throughout the 7-year follow-up period. Age modified the effect of DM in the long term, with an observed increase in risk in the ≤65 age group but not in the >65 age group.

Stages and Processes of Change for Weight Loss in Acute Stroke or TIA Patients Living with Obesity

Background: Obesity is associated with an increased prevalence of vascular risk factors and incidence of stroke. As such weight loss is recommended for patients living with obesity in the secondary prevention of stroke. Few studies, however, have examined the stages and processes of change for weight loss in stroke patients living with obesity. Objective: To evaluate the stages and processes of change for weight loss in patients living with obesity who have had a recent stroke or TIA. Methods: Using a validated questionnaire, we assessed each patient’s stage of behavioral change according to the Transtheoretical Model (precontemplation, contemplation, preparation, action and maintenance). We also examined four processes of behavioral change, which quantify activities and experiences that patients undergo on the way to behavioral change: emotional re-evaluation (EMR), weight management action (WMA), weight consequence evaluation (WCE), and supporting relationships (SR). Processes scores were compared between patients in the action and maintenance stages and those in the precontemplation, contemplation and preparation stages. Results: Out of 49 patients who provided informed consent, 44 met the inclusion/exclusion criteria. Of these 44 patients, 6 (14%) were in the precontemplation stage of change, 7 (16%) were in contemplation, 2 (5%) were in preparation, 13 (30%) were in action, and 16 (36%) were in maintenance. Those in the action and maintenance stages accounted for the majority of participants (n=29, 66%). Patients in the action and maintenance stages (N=29) had higher EMR scores (mean 79, SD 13 vs mean 68, SD 19, t=2.0, p=0.03) and WMA scores (mean 69, SD 13 vs mean 59, SD 19, t=2.0, p=0.03) as compared to those in the precontemplation, contemplation and preparation stages (N=15). Conclusions: Our results suggest that without counseling or specific intervention, approximately two-thirds of stroke/TIA patients living with obesity are in the action or maintenance stage of behavior change with respect to weight loss and therefore more likely to succeed in intensive lifestyle-based interventions targeted towards weight loss. Patients who score higher in EMR and WMA are more likely to be in the action or maintenance stage of change.

Changing the landscape of stroke in Egypt

Egypt, a low–middle-income country, is the most populated nation in the Middle East. In Egypt, the overall crude prevalence rate of stroke is high (963/100,000 inhabitants), and the incidence of stroke annually is approximately 150 000 to 210 000. The official national statistics indicate that diseases of the circulatory system, including stroke, are the primary cause of death in Egypt, where stroke accounts for 6.4% of all deaths and ranks third after cardiovascular and gastrointestinal diseases. Although the number of deaths attributed to stroke have declined in many countries, in Egypt, it was relatively unchanged in the past 10 years.

10th Anniversary of Asia Pacific Stroke Organization: State of Stroke Care and Stroke Research in the Asia Pacific

The Asia Pacific Stroke Organization is the largest international and professional stroke group in the region. It has worked consistently over the last 10 years to gain visibility and reliability across the Asia Pacific and beyond. The 10 year journey will be reviewed in the background of many internal and external developments including changes in Asia Pacific stroke epidemiology, stroke care systems, stroke service developments as well as major research studies in the Asia Pacific.

Modeling the Impact of Prehospital Triage on a True-Life Drip and Ship Mechanical Thrombectomy Urban Patient Cohort

<b><i>Objective:</i></b> The aim of the study was to model the effect of prehospital triage of emergent large vessel occlusion (ELVO) to endovascular capable center (ECC) on the timing of thrombectomy and intravenous (IV) thrombolysis using real-world data from a multihospital system. <b><i>Methods:</i></b> We selected a cohort of 77 consecutive stroke patients who were brought by emergency medical services (EMS) to a nonendovascular capable center and then transferred to an ECC for mechanical thrombectomy (MT) (“actual” drip and ship [DS] cohort). We created a hypothetical scenario (bypass model [BM]), modeling transfer of the patients directly to an ECC, based on patients’ initial EMS pickup address and closest ECC. Using another cohort of 73 consecutive patients, who were brought directly to an ECC by EMS and underwent endovascular intervention, we calculated mean door-to-needle and door-to-arterial puncture (AP) times (“actual” mothership [MS] cohort). Timings in the actual MS cohort and the actual DS cohort were compared to timings from the BM cohort. <b><i>Results:</i></b> Median first medical contact (FMC) to IV thrombolysis time was 87.5 min (interquartile range [IQR] = 38) for the DS versus 78.5 min (IQR = 8.96) for the BM cohort, with <i>p</i> = 0.1672. Median FMC to AP was 244 min (IQR = 97) versus 147 min (IQR = 8.96) (<i>p</i> &#x3c; 0.001), and median FMC to TICI 2B+ time was 299 min (IQR = 108.5) versus 197 min (IQR = 8.96) (<i>p</i> &#x3c; 0.001) for the DS versus BM cohort, respectively. <b><i>Conclusions:</i></b> Modeled EMS prehospital triage of ELVO patients’ results in shorter MT times without a change in thrombolysis times. As triage tools increase in sensitivity and specificity, EMS triage protocols stand to improve patient outcomes.

Long-term cognitive changes after revascularization surgery in adult patients with ischemic moyamoya disease

Introduction: Revascularization surgery for adult moyamoya disease (MMD) with ischemic presentation changes cognitive function and prevents further cerebral ischemic events. Most studies, however, repeated neuropsychological evaluation within 1 year after surgery. Our previous prospective cohort study of adult patients with MMD with misery perfusion who underwent direct revascularization surgery showed cognitive improvement and decline in 31% and 44%, respectively, of the patients 2 months after surgery. The present prospective study aimed to elucidate the 5-year cognitive changes after direct revascularization surgery in adult patients with cerebral misery perfusion due to ischemic MMD by following the same patients. Methods: In total, 31 patients were prospectively followed up for 5 years after direct revascularization surgery. Five types of neuropsychological tests were performed preoperatively, 2 months after surgery, and at the end of the 5-year follow-up. Cerebral blood flow in the symptomatic cerebral hemisphere relative to that in the ipsilateral cerebellar hemisphere (hemispheric RCBF) was measured using brain perfusion single-photon emission computed tomography preoperatively and at the end of the 5-year follow-up. Results: Based on results of pre- and postoperative neuropsychological tests, 11, 10, and 10 patients showed cognitive improvement, no change in cognitive function, and cognitive decline, respectively, at the end of the 5-year follow-up. These ratios were not significantly different compared with those 2 months after surgery (cognitive improvement, no change in cognitive function, and cognitive decline in 10, eight, and 13 patients, respectively). Although hemispheric RCBF was significantly greater at the end of the 5-year follow-up than before surgery in patients with cognitive improvement (80.7 ± 6.1% versus 92.9 ± 5.5%; p = 0.0033) and in those showing no change in cognitive function (85.6 ± 3.5 versus 91.5 ± 5.2%; p = 0.0093), this value was significantly lower at the end of the 5-year follow-up than before surgery in patients with cognitive decline (83.8 ± 3.7 versus 81.0 ± 5.8%; p = 0.0367). Conclusion: One-third of adult patients with cerebral misery perfusion due to ischemic MMD who underwent direct revascularization surgery exhibited cognitive improvement, and one-third exhibited decline at the end of the 5-year follow-up. The former and latter patients had increased and decreased CBF, respectively, in the affected cerebral hemisphere at the end of the 5-year follow-up compared with preoperative brain perfusion.

Short-Vessel Occlusion Might Indicate Higher Possibility of Success in Reperfusion following Mechanical Thrombectomy in Acute Middle Cerebral Artery Occlusion

<b><i>Background:</i></b> The impact of the length of the occluded vessel in acute large-vessel occlusion on successful reperfusion by mechanical thrombectomy remains unclear. This study evaluated whether diameter and length of the occluded vessel in acute middle cerebral artery (MCA) occlusion might relate to successful reperfusion following mechanical thrombectomy. <b><i>Methods:</i></b> This retrospective study included patients with acute MCA occlusion who underwent intra-aortic injection of contrast medium to obtain maximum intensity projection (MIP) images acquired by flat-panel detector computed tomography (FD-CT) equipped with an angiographic system. All patients received mechanical thrombectomy and were divided into two groups: those with successful reperfusion (Thrombolysis in Cerebral Infarction [TICI] 2b/3) and those without. We compared the diameter and length of the occluded vessel between the groups. In the sub-analysis of patients with stent retriever use, ratio of length of occluded vessel to length of the active zone was compared. <b><i>Results:</i></b> We enrolled 29 patients (median age: 73, M1 occlusion: 51%, stent retriever use: 72%). Eighteen patients achieved TICI 2b/3 with significantly larger distal end diameter (1.7 [interquartile range: 1.5–1.9] vs. 1.2 [1.2–1.5] mm, <i>p</i> = 0.007) and shorter length (7.1 [4.9–9.7] vs. 12.3 [7.2–15.8] mm, <i>p</i> = 0.043) of the occluded vessel. Sub-analysis of 21 patients showed that the cut-off value for TICI 2b/3 reperfusion was 0.32 as the ratio between the occluded vessel and stent retriever active zone (receiver operating characteristic area under the curve: 0.90). <b><i>Conclusion:</i></b> In acute MCA occlusion, larger diameter of the distal end and shorter length of the occluded vessel on FD-CT MIP images might indicate a higher possibility of achieving TICI 2b/3 following mechanical thrombectomy.

Accession Site Does Not Influence the Risk of Stroke after Diagnostic Coronary Angiography or Intervention: Results from a Large Prospective Registry

<b><i>Introduction:</i></b> Periprocedural stroke represents a rare but serious complication of cardiac catheterization. Pooled data from randomized trials evaluating the risk of stroke following cardiac catheterization via transradial versus transfemoral access showed no difference. On the other hand, a significant difference in stroke rates favoring transradial access was found in a recent meta-analysis of observational studies. Our aim was to determine if there is a difference in stroke risk after transradial versus transfemoral catheterization within a contemporary real-world registry. <b><i>Methods:</i></b> Data from 14,139 patients included in a single-center prospective registry between 2009 and 2016 were used to determine the odds of periprocedural transient ischemic attack (TIA) and stroke for radial versus femoral catheterization via multivariate logistic regression with Firth’s correction. <b><i>Results:</i></b> A total of 10,931 patients underwent transradial and 3,208 underwent transfemoral catheterization. Periprocedural TIA/stroke occurred in 41 (0.29%) patients. Age was the only significant predictor of TIA/stroke in multivariate analysis, with each additional year representing an odds ratio (OR) = 1.09 (CI 1.05–1.13, <i>p</i> &#x3c; 0.000). The choice of accession site had no impact on the risk of periprocedural TIA/stroke (OR = 0.81; CI 0.38–1.72, <i>p</i> = 0.577). <b><i>Conclusion:</i></b> Observational data from a large prospective registry indicate that accession site has no influence on the risk of periprocedural TIA/stroke after cardiac catheterization.

Stroke Care in Pakistan

Increasing incidence of stroke and lack of infrastructure in both urban and rural areas needs immediate attention in Pakistan. There is a high proportion of young stroke with poor stroke outcomes. Acute stroke care is scarce in Pakistan due to the small number of neurologists (1 neurologist per 1 million population), few stroke units, and limited availability of alteplase (recombinant tissue plasminogen activator) in the country.

The Feasibility of Mechanical Thrombectomy on Single-Plane Angiosuite: An In-Depth Analysis of Procedure Time

<b><i>Introduction:</i></b> Mechanical thrombectomy (MT) is usually performed on biplane (BP) angiosuites. When the BP angiosuite is not available, the single-plane (SP) angiosuite may be a substitute. However, the feasibility of MT performed on the SP angiosuite is yet to be elucidated. Therefore, we investigated the alternative effect of the SP angiosuite on the detailed division of procedure time, recanalization rate, and outcome in patients with anterior circulation infarction. <b><i>Methods:</i></b> The subjects included 80 consecutive patients with anterior circulation infarction who underwent MT at our hospital between May 2015 and December 2020. Demographics and characteristics of the BP and SP groups were assessed and compared. The time from puncture to guiding catheter placement (P-G), time from guiding catheter placement to recanalization (G-R), and time from puncture to recanalization (P-R) were also extracted. A good outcome was defined as a modified Rankin scale score ≤2 at 3 months. <b><i>Results:</i></b> Of the 80 patients, 67 and 13 were treated with BP and SP angiosuites, respectively. There were no differences in age, sex, complications, Alberta Stroke Program Early CT Score, National Institutes of Health Stroke Scale score at onset, occlusion site, rate of recombinant tissue-type plasminogen activator administration, stroke subtype, recanalization rate, and complications between the 2 groups. The rate of a good outcome was not different between the 2 groups. P-G was significantly longer in the SP group than in the BP group, whereas there was no significant difference in G-R and P-R between the 2 groups (P-G: BP 29.9 ± 21.8 vs. SP 48.5 ± 43.6 min, <i>p</i> = 0.04). <b><i>Conclusion:</i></b> MT performed on the SP angiosuite tended to prolong the time for guiding catheter placement. However, there was no difference in the overall procedure time, recanalization rate, or outcome between BP and SP angiosuites. Therefore, if the BP angiosuite is not available, the use of the SP angiosuite should be encouraged.