Sex differences in etiology and short-term outcome in young ischemic stroke patients receiving mechanical thrombectomy

BACKGROUND: Although there are well known sex differences in older patients with ischemic stroke receiving acute reperfusion treatments, there is paucity of data in younger patients. METHODS: We investigated sex-related differences in clinical presentation, stroke etiology and short-term outcomes in consecutive young patients with acute ischemic stroke (AIS) below the age of 50 years receiving mechanical thrombectomy (MT) between January 2011 and May 2021 in a tertiary stroke center. RESULTS: We identified a total of 202 young ischemic stroke patients with MT, with 51% being female. Young female AIS patients were significantly younger (39 ± 8 vs. 43 ± 7 years, p < 0.001), and presented with a trend for more severe stroke on admission (median NIHSS 12 vs. 9, p = 0.065), compared to males, respectively. Young female AIS patients had higher rates of embolic strokes of determined or undetermined sources in the anterior circulation, while young male AIS patients suffered more often strokes of arterio-arterial embolism. Complete reperfusion (TICI score 3) was achieved significantly less often in young female AIS patients (69% vs. 83%, p = 0.006), and in-hospital mortality was 2-times higher (5% vs. 2%, p = 0.271) compared to males. CONCLUSIONS: Young female AIS patients receiving MT have higher rates of severe embolic strokes and less often complete reperfusion due to different occlusion sites and stroke etiology compared to males

Clinical, Neuroimaging, and Genetic Markers in Cerebral Amyloid Angiopathy-Related Inflammation: A Systematic Review and Meta-Analysis

Background: There are limited data regarding the prevalence of distinct clinical, neuroimaging and genetic markers among patients diagnosed with cerebral amyloid angiopathy-related inflammation (CAA-ri). We sought to determine the prevalence of clinical, radiological, genetic and cerebrospinal fluid biomarker findings in patients with CAA-ri. Methods: A systematic review and meta-analysis of published studies including patients with CAA-ri was conducted to determine the prevalence of clinical, neuroimaging, genetic and cerebrospinal fluid biomarker findings. Subgroup analyses were performed based on (1) prospective or retrospective study design and (2) CAA-ri diagnosis with or without available biopsy. We pooled the prevalence rates using random-effects models and assessed the heterogeneity using Cochran-Q and I2-statistics. Results: We identified 4 prospective and 17 retrospective cohort studies comprising 378 patients with CAA-ri (mean age, 71.5 years; women, 52%). The pooled prevalence rates were as follows: cognitive decline at presentation 70% ([95% CI, 54%-84%]; I2=82%), focal neurological deficits 55% ([95% CI, 40%-70%]; I2=82%), encephalopathy 54% ([95% CI, 39%-68%]; I2=43%), seizures 37% ([95% CI, 27%-49%]; I2=65%), headache 31% ([95% CI, 22%-42%]; I2=58%), T2/fluid-attenuated inversion recovery-hyperintense white matter lesions 98% ([95% CI, 93%-100%]; I2=44%), lobar cerebral microbleeds 96% ([95% CI, 92%-99%]; I2=25%), gadolinium enhancing lesions 54% ([95% CI, 42%-66%]; I2=62%), cortical superficial siderosis 51% ([95% CI, 34%-68%]; I2=77%) and lobar macrohemorrhage 40% ([95% CI, 11%-73%]; I2=88%). The prevalence rate of the ApoE (Apolipoprotein E) ϵ4/ϵ4 genotype was 34% ([95% CI, 17%-53%]; I2=76%). Subgroup analyses demonstrated no differences in these prevalence rates based on study design and diagnostic strategy. Conclusions: Cognitive decline was the most common clinical feature. Hyperintense T2/fluid-attenuated inversion recovery white matter lesions and lobar cerebral microbleeds were by far the most prevalent neuroimaging findings. Thirty-four percent of patients with CAA-ri have homozygous ApoE ϵ4/ϵ4 genotype and scarce data exist regarding the cerebrospinal fluid biomarkers and its significance in these patients

Association of statin pretreatment with collateral circulation and final infarct volume in acute ischemic stroke patients: A meta-analysis

Statin pretreatment (SP) is associated with improved outcomes in acute ischemic stroke (AIS) patients. Collateral circulation status and final infarct volume (FIV) are independent predictors of functional outcome in AIS.info:eu-repo/semantics/publishedVersio

Fatal Intracranial Hemorrhage Occurring after Oral Anticoagulant Treatment Initiation for Secondary Stroke Prevention in Patients with Atrial Fibrillation

BACKGROUND AND PURPOSE: In this pooled analysis of 7 multicenter cohorts we investigated potential differences in the incidence, characteristics and outcomes between intracranial hemorrhages (ICHs) associated with the use of non-vitamin K oral anticoagulants (NOAC-ICH) or vitamin K antagonists (VKA-ICH) in ischemic stroke (IS) patients after oral anticoagulant treatment initiation for atrial fibrillation (AF). METHODS: We included data from 4.912 eligible AF patients who were admitted in a stroke unit with IS or transient ischemic attack (TIA) and who were treated with either VKAs or NOACs within 3 months post-stroke. Fatal ICH was defined as death occurring during the first 30-days after ICH onset. We additionally performed a meta-analysis of available observational studies reporting 30-day mortality rates from NOAC-ICH or VKA-ICH onset. RESULTS: During 5970 patient-years of follow-up 71 participants had an ICH, of whom 20 were NOAC-ICH and 51 VKA-ICH. Patients in the two groups had comparable baseline characteristics, except for the higher prevalence of kidney disease in VKA-ICH patients. There was a non-significant higher number of fatal ICH in patients with VKA (11 events per 3,385 patient-years) than in those with NOAC (3 events per 2,623 patient-years; HR=0.32,95%CI:0.09-1.14). Three-month functional outcomes were similar (p>0.2) in the two groups. The meta-analysis showed a lower 30-day mortality risk for patients with NOAC-ICH compared to VKA-ICH (RR=0.70,95%CI:0.51-0.95). CONCLUSIONS: NOAC-ICH and VKA-ICH occurring during secondary stroke prevention of AF patients have comparable baseline characteristics and outcomes, except for the risk of fatal ICH within 30 days, which might be greater in VKA-ICH

Multi-modality curative treatment of salivary gland cancer liver metastases with drug-eluting bead chemoembolization, radiofrequency ablation, and surgical resection: a case report

<p>Abstract</p> <p>Introduction</p> <p>Liver metastases are rare in salivary gland tumors and have been reported only once to be the first manifestation of the disease. They are usually treated with surgical resection of the primary tumor and systemic chemotherapy. Drug-eluting bead chemoembolization has an evolving role in the treatment of hepatocellular carcinoma, as well as in the treatment of metastatic disease of the liver. Nevertheless, it has never been used in a patient with salivary gland liver metastases.</p> <p>Case presentation</p> <p>We report a case of a 51-year-old Caucasian Greek woman who presented to our hospital with liver metastases as the first manifestation of an adenoid cystic carcinoma of the left submandibular gland. The liver lesions were deemed inoperable because of their size and multi-focality and proved resistant to systemic chemotherapy. She was curatively treated with a combination of doxorubicin eluting bead (DC Beads) chemoembolization, intra-operative and percutaneous radiofrequency ablation, and radiofrequency-assisted surgical resection. The patient remained disease-free one year after the surgical resection.</p> <p>Conclusion</p> <p>In conclusion, this complex case is an example of inoperable liver metastatic disease from the salivary glands that was refractory to systemic chemotherapy but was curatively treated with a combination of locoregional therapies and surgery. A multi-disciplinary approach and the adoption of modern radiological techniques produced good results after conventional therapies failed and there were no other available treatment modalities.</p

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

Chronic limb-threatening ischemia (CLTI)is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG)are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD)in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI)is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR)hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP)and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen)has not been established. Regenerative medicine approaches (eg, cell, gene therapies)for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative. © 2019 Society for Vascular Surgery and European Society for Vascular Surger

Practical guidelines for rigor and reproducibility in preclinical and clinical studies on cardioprotection

The potential for ischemic preconditioning to reduce infarct size was first recognized more than 30 years ago. Despite extension of the concept to ischemic postconditioning and remote ischemic conditioning and literally thousands of experimental studies in various species and models which identified a multitude of signaling steps, so far there is only a single and very recent study, which has unequivocally translated cardioprotection to improved clinical outcome as the primary endpoint in patients. Many potential reasons for this disappointing lack of clinical translation of cardioprotection have been proposed, including lack of rigor and reproducibility in preclinical studies, and poor design and conduct of clinical trials. There is, however, universal agreement that robust preclinical data are a mandatory prerequisite to initiate a meaningful clinical trial. In this context, it is disconcerting that the CAESAR consortium (Consortium for preclinicAl assESsment of cARdioprotective therapies) in a highly standardized multi-center approach of preclinical studies identified only ischemic preconditioning, but not nitrite or sildenafil, when given as adjunct to reperfusion, to reduce infarct size. However, ischemic preconditioning—due to its very nature—can only be used in elective interventions, and not in acute myocardial infarction. Therefore, better strategies to identify robust and reproducible strategies of cardioprotection, which can subsequently be tested in clinical trials must be developed. We refer to the recent guidelines for experimental models of myocardial ischemia and infarction, and aim to provide now practical guidelines to ensure rigor and reproducibility in preclinical and clinical studies on cardioprotection. In line with the above guideline, we define rigor as standardized state-of-the-art design, conduct and reporting of a study, which is then a prerequisite for reproducibility, i.e. replication of results by another laboratory when performing exactly the same experiment