Delayed Diagnosis in Cerebral Venous Thrombosis: Associated Factors and Clinical Outcomes.

Background Identifying factors associated with delayed diagnosis of cerebral venous thrombosis (CVT) can inform future strategies for early detection. Methods and Results We conducted a retrospective cohort study including all participants from ACTION-CVT (Anticoagulation in the Treatment of Cerebral Venous Thrombosis) study who had dates of neurologic symptom onset and CVT diagnosis available. Delayed diagnosis was defined as CVT diagnosis occurring in the fourth (final) quartile of days from symptom onset. The primary study outcome was modified Rankin Scale score of ≤1 at 90 days; secondary outcomes included partial/complete CVT recanalization on last available imaging and modified Rankin Scale score of ≤2. Logistic regression analyses were used to identify independent variables associated with delayed diagnosis and to assess the association of delayed diagnosis and outcomes. A total of 935 patients were included in our study. Median time from symptom onset to diagnosis was 4 days (interquartile range, 1-10 days). Delayed CVT diagnosis (time to diagnosis >10 days) occurred in 212 patients (23%). Isolated headache (adjusted odds ratio [aOR], 2.36 [95% CI, 1.50-3.73]; P10 days after symptom onset. Delayed CVT diagnosis was associated with the symptom of isolated headache and was not associated with adverse clinical outcomes

Factors impacting D-dimer levels in patients with acute ischemic cerebrovascular events.

BACKGROUND AND OBJECTIVES A better understanding of the factors influencing D-dimer levels in code stroke patients is needed to guide further investigations of concomitant thrombotic conditions. This study aimed to investigate the impact of time from symptom onset and other factors on D-dimer levels in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA). METHODS Data on consecutive AIS and TIA patients treated at our tertiary-care stroke center between January 2015 and December 2020 were retrospectively assessed. Patients with available D-dimer levels were evaluated for eligibility. Multivariable non-linear regression analyses were performed. RESULTS In total, 2467 AIS patients and 708 TIA patients were included. The median D-dimer levels differed between the AIS and TIA groups (746 µg/L [interquartile range 381-1468] versus 442 µg/L [interquartile range 244-800], p<0.001). In AIS patients, an early increase in D-dimer levels was demonstrated within the first 6 h (standardized beta coefficient [β] 0.728; 95% confidence interval [CI] 0.324-1.121). This was followed by an immediate decrease (β -13.022; 95% CI -20.401 to -5.643) and then by a second, late increase after 35 h (β 11.750; 95% CI 4.71-18.791). No time-dependent fluctuation in D-dimer levels was observed in TIA patients. CONCLUSION The time from symptom onset may affect D-dimer levels in patients with AIS but not those with TIA. Further studies confirming these findings and validating time-specific variations are needed to enable D-dimer levels to be used efficiently as an acute stroke and thrombotic risk biomarker

Association Between Stroke Presentation During Off‐Hours and Mechanical Thrombectomy

Background Access to mechanical thrombectomy (MT) in the United States remains limited. Given potential staffing challenges, we hypothesized that access to thrombectomy would be worse off hours. Methods We used 2016 to 2018 all‐payer claims data from all nonfederal emergency departments and acute care hospitals across 11 US states encompassing 80 million residents. Using recorded arrival times, hospital presentation was classified as on hours if it fell between 8:00 a.m. and 6:00 p.m. on weekdays and as off hours otherwise. We examined the association between off‐hours arrival and MT using multiple adjusted logistic regression models. In a subset of patients with available National Institutes of Health Stroke Scale data, we performed a sensitivity analysis limited to patients who presented to a thrombectomy hub with a probable large‐vessel occlusion, defined as a documented National Institutes of Health Stroke Scale score ≥12, and underwent intravenous thrombolysis. Similar analyses were performed to assess MT odds during extreme off hours, defined as midnight to 6:00 a.m., compared to 8:00 a.m. to 2:00 p.m. Results Among 169 199 patients with ischemic stroke, the 82 784 (48.9%) who presented during off hours more often presented to thrombectomy hubs and teaching hospitals and more often received intravenous thrombolysis. Among 31 148 patients with documented National Institutes of Health Stroke Scale scores, those presenting off hours had higher scores (4 [interquartile range, 2–10] versus 2 [interquartile range, 1–9]; P<0.001). There were no differences between groups in rates of MT (3.4% on hours versus 3.5% off hours; P=0.25). In adjusted models, off‐hours presentation was not significantly associated with lower odds of MT (odds ratio [OR], 0.94; [95% CI, 0.85–1.03]). Our findings were similar in a sensitivity analysis limited to patients with a probable large‐vessel occlusion who initially presented to a thrombectomy hub and underwent intravenous thrombolysis (OR, 0.87; [95% CI, 0.69–1.09]). Extreme off‐hours presentation was associated with a lower likelihood of MT (OR, 0.83; [95% CI, 0.75–0.93]). Conclusion In a large, population‐based sample of ischemic stroke patients across the United States, the odds of MT were similar during on and off hours. Extreme off hours seem to be associated with decreased access to treatment

supplement_fig - Clinical Decision-Making for Thrombolysis of Acute Minor Stroke Using Adaptive Conjoint Analysis

<p>supplement_fig for Clinical Decision-Making for Thrombolysis of Acute Minor Stroke Using Adaptive Conjoint Analysis by Ava L. Liberman, Daniel Pinto, Sara K. Rostanski, Daniel L. Labovitz, Andrew M. Naidech, and Shyam Prabhakaran in The Neurohospitalist</p

Cost‐Effectiveness of Increased Use of Dual Antiplatelet Therapy After High‐Risk Transient Ischemic Attack or Minor Stroke

Background Rates of dual antiplatelet therapy (DAPT) after high‐risk transient ischemic attack or minor ischemic stroke (TIAMIS) are suboptimal. We performed a cost‐effectiveness analysis to characterize the parameters of a quality improvement (QI) intervention designed to increase DAPT use after TIAMIS. Methods and Results We constructed a decision tree model that compared current national rates of DAPT use after TIAMIS with rates after implementing a theoretical QI intervention designed to increase appropriate DAPT use. The base case assumed that a QI intervention increased the rate of DAPT use to 65% from 45%. Costs (payer and societal) and outcomes (stroke, myocardial infarction, major bleed, or death) were modeled using a lifetime horizon. An incremental cost‐effectiveness ratio <$100 000 per quality‐adjusted life year was considered cost‐effective. Deterministic and probabilistic sensitivity analyses were performed. From the payer perspective, a QI intervention was associated with$9657 in lifetime cost savings and 0.18 more quality‐adjusted life years compared with current national treatment rates. A QI intervention was cost‐effective in 73% of probabilistic sensitivity analysis iterations. Results were similar from the societal perspective. The maximum acceptable, initial, 1‐time payer cost of a QI intervention was $28 032 per patient. A QI intervention that increased DAPT use to at least 51% was cost‐effective in the base case. Conclusions Increasing DAPT use after TIAMIS with a QI intervention is cost‐effective over a wide range of costs and proportion of patients with TIAMIS treated with DAPT after implementation of a QI intervention. Our results support the development of future interventions focused on increasing DAPT use after TIAMIS

Association of Assisted Reproductive Technology and Stroke During Hospitalization for Delivery in the United States

INTRODUCTION: Infertility treatment with assisted reproductive technologies (ARTs) has been associated with adverse vascular events in some but not all previous studies. Endothelial damage, prothrombotic factor release, and a higher prevalence of cardiovascular risk factors in those receiving ART have been invoked to explain this association. We sought to explore the relationship between ART and stroke risk using population-level data. METHODS: We conducted a retrospective cohort study using data from the National Inpatient Sample registry from 2015 to 2020, including all delivery hospitalizations for patients aged 15 to 55 years. The study exposure was use of ART. The primary end point was any stroke defined as ischemic stroke, subarachnoid hemorrhage, intracerebral hemorrhage, or cerebral venous thrombosis during index delivery hospitalization. Individual stroke subtypes (ischemic stroke, subarachnoid hemorrhage, intracerebral hemorrhage, and cerebral venous thrombosis) were evaluated as secondary end points. Standard , Clinical Modification algorithms were used to define study exposure, comorbidities, and prespecified end points. In addition to reporting population-level estimates, propensity score adjustment by inverse probability weighting was used to mimic the effects of randomization by balancing baseline clinical characteristics associated with stroke between ART and non-ART users. RESULTS: Among 19 123 125 delivery hospitalizations identified, patients with prior ART (n=202 815, 1.1%) experienced significantly higher rates of any stroke (27.1/100 000 versus 9.1/100 000), ischemic stroke (9.9/100 000 versus 3.3/100 000), subarachnoid hemorrhage (7.4/100 000 versus 1.6/100 000), intracerebral hemorrhage (7.4/100 000 versus 2.0/100 000), and cerebral venous thrombosis (7.4/100 000 versus 2.7/100 000) in comparison to non-ART users (all \u3c0.001 for all unadjusted comparisons). Following inverse probability weighting analysis, ART was associated with increased odds of any stroke (adjusted odds ratios, 2.14 (95% CI, 2.02-2.26); \u3c0.001). CONCLUSIONS: Using population-level data among patients hospitalized for delivery in the United States, we found an association between ART and stroke after adjustment for measured confounders

Long‐term risk of seizure after posterior reversible encephalopathy syndrome

Abstract Objective Patients with posterior reversible encephalopathy syndrome (PRES) can develop seizures during the acute phase. We sought to determine the long‐term risk of seizure after PRES. Methods We performed a retrospective cohort study using statewide all‐payer claims data from 2016–2018 from nonfederal hospitals in 11 US states. Adults admitted with PRES were compared to adults admitted with stroke, an acute cerebrovascular disorder associated with long‐term risk of seizure. The primary outcome was seizure diagnosed during an emergency room visit or hospital admission after the index hospitalization. The secondary outcome was status epilepticus. Diagnoses were determined using previously validated ICD‐10‐CM codes. Patients with seizure diagnoses before or during the index admission were excluded. We used Cox regression to evaluate the association of PRES with seizure, adjusting for demographics and potential confounders. Results We identified 2095 patients hospitalized with PRES and 341,809 with stroke. Median follow‐up was 0.9 years (IQR, 0.3–1.7) in the PRES group and 1.0 years (IQR, 0.4–1.8) in the stroke group. Crude seizure incidence per 100 person‐years was 9.5 after PRES and 2.5 after stroke. After adjustment for demographics and comorbidities, patients with PRES had a higher risk of seizure than patients with stroke (HR, 2.9; 95% CI, 2.6–3.4). Results were unchanged in a sensitivity analysis that applied a two‐week washout period to mitigate detection bias. A similar relationship was observed for the secondary outcome of status epilepticus. Interpretation PRES was associated with an increased long‐term risk of subsequent acute care utilization for seizure compared to stroke