Türkiye’de inme hastalarında atrial fibrilasyonun yönetimi: NöroTek çalışması gerçek hayat verileri

Objective: Atrial fibrillation (AF) is the most common directly preventable cause of ischemic stroke. There is no dependable neurology-based data on the spectrum of stroke caused by AF in Turkiye. Within the scope of NoroTek-Turkiye (TR), hospital-based data on acute stroke patients with AF were collected to contribute to the creation of acute-stroke algorithms.Materials and Methods: On May 10, 2018 (World Stroke Awareness Day), 1,790 patients hospitalized at 87 neurology units in 30 health regions were prospectively evaluated. A total of 929 patients [859 acute ischemic stroke, 70 transient ischemic attack (TIA)] from this study were included in this analysis.Results: The rate of AF in patients hospitalized for ischemic stroke/TIA was 29.8%, of which 65% were known before stroke, 5% were paroxysmal, and 30% were diagnosed after hospital admission. The proportion of patients with AF who received "effective" treatment [international normalization ratio >= 2.0 warfarin or non-vitamin K antagonist oral anticoagulants (NOACs) at a guideline dose] was 25.3%, and, either no medication or only antiplatelet was used in 42.5% of the cases. The low dose rate was 50% in 42 patients who had a stroke while taking NOACs. Anticoagulant was prescribed to the patient at discharge at a rate of 94.6%; low molecular weight or unfractionated heparin was prescribed in 28.1%, warfarin in 32.5%, and NOACs in 31%. The dose was in the low category in 22% of the cases discharged with NOACs, and half of the cases, who received NOACs at admission, were discharged with the same drug.Conclusion: NoroTekTR revealed the high but expected frequency of AF in acute stroke in Turkiye, as well as the aspects that could be improved in the management of secondary prophylaxis. AF is found in approximately one-third of hospitalized acute stroke cases in Turkiye. Effective anticoagulant therapy was not used in three-quarters of acute stroke cases with known AF. In AF, heparin, warfarin, and NOACs are planned at a similar frequency (one-third) within the scope of stroke secondary prophylaxis, and the prescribed NOAC dose is subtherapeutic in a quarter of the cases. Non-medical and medical education appears necessary to prevent stroke caused by AF.Amaç: Atrial fibrilasyon (AF) iskemik inmenin doğrudan önlenebilir en sık nedendir. Ülkemizde AF nedenli inme spektrumuna dair nöroloji kaynaklı geniş ölçekte bir veri bulunmamaktadır. NöroTek-Türkiye (TR) kapsamında akut inme algoritmalarının oluşturulmasına katkı yapması beklenen AF tespit edilen akut inme hastalarına dair hastane verisi toplanmıştır. Gereç ve Yöntem: 10 Mayıs 2018 Dünya İnme Farkındalık Günü’nde 30 sağlık bölgesine yer alan 87 nöroloji biriminde yatmakta olan 1.790 hasta prospektif olarak değerlendirilmiştir. Çalışmada yer alan toplam 929 hasta [859 akut iskemik inme, 70 geçici iskemik atak (GİA)] bu analize dahil edilmiştir. Bulgular: İskemik inme/GİA sebebiyle ile interne edilmiş hastalarda AF oranı %29,8 olup bunların %65’i bilinmekte olan, %5’i paroksismal ve %30’u yeni tanıdır. AF tanısı ile gelen hastalarda “etkin” tedavi [internasyonel normalizasyon oranı ≥2,0 varfarin veya rehber dozunda non-vitamin K antagonist oral antikoagülan (NOAK)] alanların oranı %25,3 olup, %42,5 olguda ya hiç ilaç kullanılmamakta ya da sadece antiplatelet kullanılmaktaydı. Düşük doz kullanım oranı 42 NOAK alırken inme geçirmiş olguda %50 idi. Taburcu edilirken antikoagülan %94,6 (düşük molekül ağırlıklı veya non-fraksiyone heparin %28,1; varfarin %32,5 ve NOAK %31) hastaya reçete edilmişti. NOAK ile taburcu edilen olguların %22’sinde doz düşük kategoride olup gelişte NOAK almakta olan olguların yarısı aynı ilaçla taburcu edilmiştir. Sonuç: NöroTekTR ülkemizde AF’nin akut inmedeki sıklığı yanı sıra sekonder proflaksi perspektifinde yönetiminin geliştirilebilecek yönlerini ortaya koydu. Türkiye’de hastanede yatan akut inme olgularının yaklaşık üçte birinde AF saptanmıştır. AF’si bilinen akut inme olgularının dörtte üçünde etkin antikoagülan tedavi kullanılmamaktaydı. AF’de inme sekonder proflaksisi kapsamında heparin, varfarin ve NOAK planlaması benzer sıklıkta (üçte bir) olup reçete edilen NOAK dozu dörtte bir olguda subterapötiktir. AF’ye bağlı inmenin önlenebilmesi non-medikal ve medikal eğitim gerekli görünmektedir

A comparison of conscious sedation and local anesthesia for thrombectomy in acute ischemic stroke: a multicenter study

IntroductionIschemic cerebrovascular disease (ICVD) is a serious health problem in which brain tissue suffers from hypoxic damage due to obstruction in cerebral vessels. Mechanical thrombectomy is a commonly used method in the treatment of these patients. However, the effects of local anesthesia (LA) and conscious sedation (CS) during thrombectomy are still unclear. We evaluated whether there was a relationship between the two anesthesia regimens in terms of 90-day modified Rankin Scale (mRS) scores.MethodsIn this study, a retrospective observational study was conducted to evaluate the effects of LA and CS used during mechanical thrombectomy in four comprehensive stroke centers among ICVD patients. Patients were divided into the LA group and the CS group. Statistical analysis was performed before and after 1:1 matching under propensity score matching (PSM) analysis. The primary outcome measure was an mRS score of 0–2 at 90 days. Secondary outcomes were procedure times, recanalization rates, symptomatic and asymptomatic hemorrhage rates, and procedural complications.ResultsA total of 193 patients (118 patients with LA and 75 patients with CS) were included in the final analysis before PSM. After 1:1 PSM, 98 patients—49 patients from each group—were included in the study. There was no difference in clinical outcomes between the LA- and CS-applied groups (p = 0.543). When blood pressure (BP) values at follow-up after endovascular treatment (EVT) were compared, the lowest systolic and lowest diastolic BP were found to be lower in the CS group (p = 0.001 and p = 0.009). There was no significant difference between the two groups in terms of recanalization rates, symptomatic intracranial hemorrhage (sICH) rates, 90-day mRS, and procedure-related complication rates (p = 0.617, p = 0.274, p = 0.543, and p = 1.000).ConclusionThis study did not reveal the superiority of CS applied during EVT on 90-day mRS, sICH, recanalization rates, or procedural complications. However, the risk of developing hypotension during the CS application was found to be high

Spontan Recanalization of Internal Carotis Artery Occlusion: A Case Report

There is not too much literature knowledge about spontaneous recanalization of the internal carotid artery (ICA) occlusions following and treatment. Here we presented a case who could have the opportunity of carotid artery stending treatment, where it is incidentally revealed that the occlusion of ICA is recanalized. The purpose of this case report is to emphasize the importance of ICA spontaneous recanalization

Coexistence of external carotid artery embolus and internal carotid artery occlusion in acute ischemic stroke: An indicator of cardioembolic etiology?

Objectives: This study aims to evaluate whether the presence of an external carotid artery embolism accompanying internal carotid artery occlusion may contribute to identifying the etiology of internal carotid artery occlusion in the early period. Mate-rial and methods: The presence of external carotid artery embolism was evaluated in 117 patients who were adjudicated for internal carotid artery occlusion based on digital subtraction angiography images. Results: Embolus in the external carotid artery was detected in 8 (6.8%) of the 117 patients with internal carotid artery occlu-sion (7 (87.5%) patients were found to have tandem and 1 (12.5%) patient had carotid T occlusion). In all of these patients, the thrombus was of embolic origin. Evaluation of the etiology revealed cardioembolic etiology in 4 patients and dissec-tion in 1 patient, and the cause could not be determined in the remaining 3 patients. Patients with external carotid artery embolism accompanying an internal carotid artery occlusion had significantly higher The National Institutes of Health Stroke Scale scores at admission and significantly lower recanalization success compared to those without external carotid artery embolism (p = 0.009, p = 0.01). In the com-parison of prognosis, poorer prognosis was observed in those with external carotid artery embolism, although without a statistically significant difference (p = 0.07). Conclusions: This study observed that the etiology was mostly embolic in patients with external carotid artery embolism accompanying an internal carotid artery occlusion, most of whom were found to have tandem embolic occlusion, and car-diac origin appeared to be the prominent etiology of stroke

Vagal Nerve Stimulation in the Treatment of Olanzapine Related Super Refractory Status Epilepticus: A Case Report

Olanzapine-related seizures have rarely been reported despite associated proconvulsant risk factors described in the literature. Refractory and super refractory status epilepticus is continuous seizure activity not controlled by antiepileptic drugs and related poor outcomes. Because of high mortality with polypharmacy and continuous anesthetic use, there has been a considerable interest in using nonmedicinal devices like vagal nerve stimulation in aborting a seizure. In this case study, we presented a patient who developed generalized tonic-clonic seizures when olanzapine was added for psychomotor agitation and aggressiveness and super refractory status epilepticus treated using vagal nerve stimulation

Anesthesia Strategies in Endovascular Treatment

Endovascular treatment modalities that directly retrieve the clot have become standard strategies in the care of acute ischemic stroke with major vessel occlusion in selected patient groups. The anesthetic strategy applied in the perioperative stage of endovascular treatment should be well determined in order to minimize loss of time and to maintain hemodynamic stability. Most retrospective studies in previous years have shown that conscious sedation may be more advantageous. However, in recent randomized controlled trials, it has not been shown that general anesthesia leads to worse neurological outcomes when compared to conscious sedation. In this review, the effect of anesthetic strategy selection on patient outcome will be presented in the context of recent publications

A stroke form fluctuating in acute stroke: Capsular warning syndrome

Capsular warning syndrome is an important clinical entity because of its typical story, presentation and increased risk of symptom recurrence recurrence. Since the pathophysiology of this syndrome has not be fully understood, there is no consensus on the treatment approach. Furthermore, clinical deterioration may occur despite antiplatelet, anticoagulant or trombolytic treatments. We aimed to present three cases with capsular warning syndrome to discuss their clinical presentations, radiological findings and to underline that prevention of its progression to a completed stroke may be difficult

Sporadic Creutzfeldt-Jacob Disease: Analysis of 16 Patients

Objectives:Creutzfeldt-Jacob Disease (CJD) is a rare neurodegenerative disorder. This study is a review of clinical findings and diagnostic procedures used for 16 patients diagnosed with sporadic CJD (sCJD) at Ankara University School of Medicine.Methods:Medical records of 16 patients who were diagnosed with sCJD between January 1990 and January 2015 were analyzed. Clinical features, periodic sharp and slow wave complexes (PSSW) in electroencephalography (EEG), finding of 14-3-3 protein in cerebrospinal fluid (CSF) and brain magnetic resonance imaging (MRI) of all patients were assessed.Results:Study included 16 patients with sCJD: 6 females (37.5%) and 10 males (62.5%), with mean age 64±9.5 years. All patients had dementia and myoclonus; 14 patients had extrapyramidal or pyramidal signs, 13 had cerebellar (n=10) and/or visual signs (n=6), and 10 patients had akinetic mutism. PSSW were present in EEG of 13 patients. Brain MRI of 13 patients showed abnormalities and 14-3-3 protein was detected in CSF of 6 of 7 patients. Within an average period of 3 months from the onset of signs, 9 hospitalized patients died.Conclusion:It is important to consider diagnosis of sCJD in patients with rapidly progressive dementia

Role of modified TAN score in predicting prognosis in patients with acute ischemic stroke undergoing endovascular therapy

Objective: The study aimed to evaluate the prognostic role of modified TAN collateral score in predicting functional independence in ischemic stroke patients, who underwent endovascular therapy. Introduction: Identifying the group of patients, who will benefit most from arterial recanalization in patients with acute ischemic stroke, is the basis of success. Collateral circulation is a physiological condition that protects the brain against ischemia and inhibits the growth of a damaged area. The presence of collaterals is a well-known determinant for functional independence. Numerous collateral scoring systems are used for this purpose. The aim of this study was to evaluate the prognostic role of modified TAN collateral score (MTCS) in predicting functional independence in patients, who received endovascular therapy. Materials and methods: Prospective data of 101 patients, who received endovascular therapy from the stroke team of Eskisehir Osmangazi University (ESOGU) between 2016 and 2017, were examined retrospectively for this purpose. Collateral assessments were performed in Computed Tomography Angiography (CTA) according to the modified TAN scoring system (= 50% refers to good collateral status). Good clinical outcome was assessed as mRS 0-2 in the 3rd month. The TICI scoring system was used in the evaluation of recanalization. Patients treated within the first 6 h of symptom onset, patients with NCCT and contrast CTA, patients with internal carotid artery and middle cerebral artery occlusion were included in the study. Posterior system stroke was not included in the study. Conclusion: Of the 101 patients, 50 (49%) had poor MTCS. Presentation and 24th hour NIHSS values of the patients with poor MTCS were higher (p:0.003). The third month mRS values were low in patients with good MTCS on admission, while these values were high in patients, who presented with poor MTCS. Mortality rates were significantly higher in the patient group with poor collateral circulation score (32-5.9%) (p:0.001). No significant differences were found in the presentation ASPECT values and (TICI 2b/3) recanalization rates of the patients. The rate of futile recanalization was significantly higher in the group with poor collateral circulation (52-8%) (p:0.0001). Presentation glucose, NIHSS, mTAN, symptom-puncture time, and good ASPECT score were found to be predictive markers for good outcome by univariate analysis. The major risk factors were determined by performing multiple logistic regression analysis. Presentation glucose, NIHSS, and mTAN (OR:1.013, 1.29, 0.198, respectively) were found to be strong and independent predictors for good clinical outcome. According to Multiple Binary Logistic Regression analysis Backward-ward model, Baseline NIHSS, poor collaterals and baseline glucose are found as predictors for poor outcome. Discussion: This study shows that good collateral score is associated with good clinical response, small final infarct volume, third month low mRS, low admission, and 24-hour NIHSS rates. The likelihood of having long term prognosis is 7 fold higher in patients with poor collaterals. The use of the MTCS system is recommended and supported due to its easy and rapid applicability

Gastrostomy in Hospitalized Patients with Acute Stroke: NoroTek Turkey Point Prevalence Study Subgroup Analysis

Objective: Nutritional status assessment, dysphagia evaluation and enteral feeding decision are important determinants of prognosis in acute neurovascular diseases. Materials and Methods: NoroTek is a point prevalence study conducted with the participation of 87 hospitals spread across all health sub regions of Turkey conducted on 10-May-2018 (World Stroke Awareness Day). A total of 972 hospitalized neurovascular patients [female: 53%, age: 69 +/- 14; acute ischemic stroke in 845; intracerebral hematoma (ICH) in 119 and post-resuscitation encephalopathy (PRE) in 8] with complete data were included in this sub-study. Results: Gastrostomy was inserted in 10.7% of the patients with ischemic stroke, 10.1% of the patients with ICH and in 50% of the patients with PRE. Independent predictors of percutaneous endoscopic gastrostomy (PEG) administration were The National Institutes of Health Stroke Scale score at admission [exp (ss): 1.09 95% confidence interval (CI): 1.05-1.14, per point] in ischemic stroke; and mechanical ventilation in ischemic [exp (ss): 6.18 (95% CI: 3.16-12.09)] and hemorrhagic strokes [exp (ss): 26.48 (95% CI: 1.36-515.8)]. PEG was found to be a significant negative indicator of favorable (modified Rankin's scale score 0-2) functional outcome [exp (ss): 0.032 (95% CI: 0.004-0.251)] but not of in-hospital mortality [exp (ss): 1.731 (95% CI: 0.785-3.829)]. Nutritional and swallowing assessments were performed in approximately two-thirds of patients. Of the nutritional assessments 69% and 76% of dysphagia assessments were completed within the first 2 days. Tube feeding was performed in 39% of the patients. In 83.5% of them, tube was inserted in the first 2 days; 28% of the patients with feeding tube had PEG later. Conclusion: The NoroTek study provided the first reliable and large-scale data on key quality metrics of nutrition practice in acute stroke in Turkey. In terms of being economical and accurate it makes sense to use the point prevalence method