The influence of imaging features of brain frailty on outcomes were investigated in acute ischemic stroke patients with minor symptoms and large-vessel occlusion (LVO).
Background: Although dual antiplatelet treatment with aspirin and clopidogrel is widely used in stroke patients due to large artery atherosclerosis (LAA), there are limited data to justify this. Methods: We used a multicenter, prospective stroke registry database (CRCS-K) to analyze acute ischemic stroke patients due to LAA who were treated with aspirin alone or combination of aspirin and clopidogrel from May, 2008 to May 2015. Results were analyzed by intention-to-treat (ITT), as-treated (AT), and per-protocol (PP) method. Primary endpoint was the 1-year composite outcome of stroke recurrence, myocardial infarction (MI), and all-cause death. To balance the differences between groups, a frailty model with inverse probability of treatment weighting was used. Results: A total of 5,934 patients due to LAA were treated either aspirin alone (n=3,031, 51%) or combination of aspirin and clopidogrel (n=2,903, 49%). Primary outcome was 14% (n=410) in aspirin alone group and 12% (n=353) in aspirin plus clopidogrel group. In ITT analysis, compared to aspirin alone, aspirin plus clopidogrel did not decrease the hazards of primary outcome (adjusted hazards ratio, 0.86; 95% confidence intervals, 0.74-1.01; p=0.06), but decreased all-cause mortality significantly (0.80; 0.66-0.98; p=0.03). Stroke recurrence and a composite of stroke recurrence, MI, and vascular death were not reduced by aspirin plus clopidogrel. Results of AT and PP analyses are shown in the table below. Conclusion: Addition of clopidogrel to aspirin may decrease all-cause death and perhaps the composite of stroke recurrence, MI and all-cause death in patients with large artery atherosclerotic stroke.
Cerebral infarction is known to cause secondary degeneration of the areas connected to the primarily damaged regions. This has been named as acute network injury and is usually recognized in newborns or babies by high signal intensity on diffusion-weighted imaging (DWI). In this article, we present 2 cases demonstrating several characteristics of network injury. Some features are comparable to previous studies and others are distinctive to our cases. The patients not only showed secondary injury in the thorough pyramidal tract along the longitudinal extensions of neural tracts as expected but also followed transverse connections to reach the contralateral hemisphere. The location of network injury varied according to the initial lesion and projected in an omnidirectional manner as long as the brain parts are interconnected. In addition, the cases well demonstrated the temporal changes on brain imaging. Network injury appeared on DWI around a week after major damage and then subsequently disappeared. The overall process of appearance to disappearance was completed within 2 weeks from the symptom onset. As ominous neurological outcomes are thought to be related to acute network injuries, a comprehensive understanding of the phenomenon is pivotal in improving diagnosis and management.
About 30%-40% of stroke patients are taking antiplatelet at the time of their strokes, which might increase the risk of symptomatic intracranial hemorrhage (SICH) with intravenous tissue plasminogen activator (IV-TPA) therapy. We aimed to assess the effect of prestroke antiplatelet on the SICH risk and functional outcome in Koreans treated with IV-TPA.From a prospective stroke registry, we identified patients treated with IV-TPA between October 2009 and November 2014. Prestroke antiplatelet use was defined as taking antiplatelet within 7 days before the stroke onset. The primary outcome was SICH. Secondary outcomes were discharge modified Rankin Scale (mRS) score and in-hospital mortality.Of 1,715 patients treated with IV-TPA, 441 (25.7%) were on prestroke antiplatelet. Prestroke antiplatelet users versus non-users were more likely to be older, to have multiple vascular risk factors. Prestroke antiplatelet use was associated with an increased risk of SICH (5.9% vs. 3.0%; adjusted odds ratio [OR] 1.79 [1.05-3.04]). However, at discharge, the two groups did not differ in mRS distribution (adjusted OR 0.90 [0.72-1.14]), mRS 0-1 outcome (34.2% vs. 33.7%; adjusted OR 1.27 [0.94-1.72), mRS 0-2 outcome (52.4% vs. 52.9%; adjusted OR 1.21 [0.90-1.63]), and in-hospital mortality (6.1% vs. 4.2%; adjusted OR 1.19 [0.71-2.01]).Despite an increased risk of SICH, prestroke antiplatelet users compared to non-users had comparable functional outcomes and in-hospital mortality with IV-TPA therapy. Our results support the use of IV-TPA in eligible patients taking antiplatelet therapy before their stroke onset.
A high and low estimated glomerular filtration rate (eGFR) could affect outcomes after reperfusion therapy for ischemic stroke. This study aimed to determine whether renal function based on eGFR affects mortality risk in patients with ischemic stroke within 6 months following reperfusion therapy.This prospective registry-based cohort study included 2266 patients who received reperfusion therapy between January 2000 and September 2019 and were registered in the SECRET (Selection Criteria in Endovascular Thrombectomy and Thrombolytic Therapy) study or the Yonsei Stroke Cohort. A high and low eGFR were based on the Chronic Kidney Disease Epidemiology Collaboration equation and defined, respectively, as the 5th and 95th percentiles of age- and sex-specific eGFR. Occurrence of death within 6 months was compared among the groups according to their eGFR such as low, normal, or high eGFR.Of the 2266 patients, 2051 (90.5%) had a normal eGFR, 110 (4.9%) a low eGFR, and 105 (4.6%) a high eGFR. Patients with high eGFR were younger or less likely to have hypertension, diabetes, or atrial fibrillation than the other groups. Active cancer was more prevalent in the high-eGFR group. During the 6-month follow-up, there were 24 deaths (22.9%) in the high-eGFR group, 37 (33.6%) in the low-eGFR group, and 237 (11.6%) in the normal-eGFR group. After adjusting for variables with P<0.10 in the univariable analysis, 6-month mortality was independently associated with high eGFR (hazard ratio, 2.22 [95% CI, 1.36-3.62]; P=0.001) and low eGFR (HR, 2.29 [95% CI, 1.41-3.72]; P=0.001). These associations persisted regardless of treatment modality or various baseline characteristics.High eGFR as well as low eGFR were independently associated with 6-month mortality after reperfusion therapy. Kidney function could be considered a prognostic factor in patients with ischemic stroke after reperfusion therapy.
Background Retinal artery occlusion can lead to sudden visual loss without pain. The acute management of retinal artery occlusion remains unresolved. Case Report A 65-year-old male was hospitalized to an emergency room for visual loss on the left side within 6 hours of onset. Combined occlusion at retinal artery and ciliary artery was confirmed by an ophthalmologist and we assessed ophthalmic artery occlusion. However, MRA revealed no significant steno-occlusion of internal carotid artery. Transfemoral cerebral angiography was carried out immediately and showed a movable thrombus at the orifice of the ophthalmic artery. We decided on endovascular thrombectomy to prevent permanent visual loss. Finally, his visual acuity was improved after successful thrombectomy. Conclusions Although MRA is intact, small thrombus right at the orifice of the ophthalmic artery can cause a sudden monocular visual loss due to occlusion of the retinal artery. In this setting, urgent endovascular thrombectomy can offer visual improvement. Key Words: Monocular blindness; Ophthalmic artery; Thrombectomy
Coronavirus disease 2019 (COVID-19) is an ongoing pandemic infection associated with high morbidity and mortality. The Korean city of Daegu endured the first large COVID-19 outbreak outside of China. Since the report of the first confirmed case in Daegu on February 18, 2020, a total of 6,880 patients have been reported until May 29, 2020. We experienced five patients with ischemic stroke and COVID-19 during this period in four tertiary hospitals in Daegu. The D-dimer levels were high in all three patients in whom D-dimer blood testing was performed. Multiple embolic infarctions were observed in three patients and suspected in one. The mean time from stroke symptom onset to emergency room arrival was 22 hours. As a result, acute treatment for ischemic stroke was delayed. The present case series report raises the possibility that the coronavirus responsible for COVID-19 causes or worsens stroke, perhaps by inducing inflammation. The control of COVID-19 is very important; however, early and proper management of stroke should not be neglected during the epidemic.
This corrects the article "Case Characteristics, Hyperacute Treatment, and Outcome Information from the Clinical Research Center for Stroke-Fifth Division Registry in South Korea" in Volume 17 on page 38.
To test whether autologous modified mesenchymal stem cells (MSCs) improve recovery in patients with chronic major stroke.
Methods
In this prospective, open-label, randomized controlled trial with blinded outcome evaluation, patients with severe middle cerebral artery territory infarct within 90 days of symptom onset were assigned, in a 2:1 ratio, to receive preconditioned autologous MSC injections (MSC group) or standard treatment alone (control group). The primary outcome was the score on the modified Rankin Scale (mRS) at 3 months. The secondary outcome was to further demonstrate motor recovery.
Results
A total of 39 and 15 patients were included in the MSC and control groups, respectively, for the final intention-to-treat analysis. Mean age of patients was 68 (range 28–83) years, and mean interval between stroke onset to randomization was 20.2 (range 5–89) days. Baseline characteristics were not different between groups. There was no significant difference between the groups in the mRS score shift at 3 months (p = 0.732). However, secondary analyses showed significant improvements in lower extremity motor function in the MSC group compared to the control group (change in the leg score of the Motricity Index, p = 0.023), which was notable among patients with low predicted recovery potential. There were no serious treatment-related adverse events.
Conclusions
IV application of preconditioned, autologous MSCs with autologous serum was feasible and safe in patients with chronic major stroke. MSC treatment was not associated with improvements in the 3-month mRS score, but we did observe leg motor improvement in detailed functional analyses.
Classification of Evidence
This study provides Class III evidence that autologous MSCs do not improve 90-day outcomes in patients with chronic stroke.
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