13 research outputs found
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Mechanical Thrombectomy for Large Vessel Occlusions in Cocaine Associated Acute Ischemic Stroke: Small Case Series and Review of the Literature
Cocaine through multifactorial pathogenetic mechanisms causes small and large vessel occlusions (LVO) leading to acute ischemic stroke. The optimal treatment for cocaine related LVO remains unknown. Mechanical thrombectomy (MT) poses a unique challenge, and successful MT are not widely reported.
We report three patients with no other risk factors and a common history of cocaine metabolites found on presentation drug screen who underwent MT for MCA occlusions with subsequent failed recanalization or vessel re-occlusion due to persistent thrombosis and severe vasospasm.Two patients initially had good revascularization but then developed severe vasospasm and reoccluded, and the remaining patient had persistent severe distal vasospasm. Rescue therapy either with balloon angioplasty with stent placement or intraarterial vasodilator was used in all patients and was ineffective. All patient had large hemispheric strokes and developed malignant cerebral edema requiring hemicraniectomy in two of them. We also did literature review and summarized previously reported cases of cocaine associated vasospasm in MT and other endovascular procedures.
In this case series, cocaine induced vasospasm contributed to unsuccessful recanalization and reocclusion in patients undergoing MT with poor outcomes. Further studies are needed to ascertain strategies for improved outcomes in patients with LVO related to cocaine use
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Abstract P256: Association Between Antidepressants Use and Intracerebral Hemorrhage: Florida Stroke Registry
Introduction: SSRIs, the most commonly prescribed antidepressants (AD) in the US, are linked to an increased intracerebral hemorrhage (ICH) risk possibly related to impaired platelet function. In the Florida Stroke Registry (FSR), we studied the proportion of cases presenting with ICH amongst AD users and the rate of SSRI prescription amongst stroke patients discharged on AD. Methods: From Jan 2010 to Dec 2019 we included 127,915 cases from FSR in whom information on AD use was available. Multivariable logistic regression was used to evaluate ICH proportions amongst AD and non-AD users and rates of prescribed SSRIs at discharge. Results: The rate of ICH amongst prior AD users (n=17,009, median age 74, IQR=19) and non-AD users (n=110,906, median age 72, IQR=21) were 11% and 14% respectively. Prior AD users were more likely to be female (17% vs. 10% male), non-Hispanic White (16% vs. 8% non-Hispanic Black vs. 12% Florida Hispanic vs. 6% Puerto Rican Hispanic), have hypertension (HTN) (14.% vs. 10%), diabetes mellitus (DM) (16% vs.12%), use oral anticoagulants (OAC) (17 % vs. 13%), antiplatelets (AP; 17% vs. 11%), and statins (17% vs. 10%) prior to hospital presentation. In multivariable analysis adjusting for age, race, prior history of HTN, DM, prior OAC, AP and statin use, AD users just as likely to present with spontaneous ICH as compared to non-AD users (OR=0.92, 95% CI 0.85, 1.01). A total of 3.4% of all ICH patients and 9% of those in whom AD information was available were discharged home on an AD (74 % SSRI, 24% other AD). Conclusion: In this large population-based study, we did not find an association between prior AD use and an increased rate of ICH. Importantly AD (mostly SSRIs) are commonly prescribed to patients with ICH in routine clinical practice. The association between types, duration, and safety of antidepressant use in ICH patients deserves further studies
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Abstract WMP84: The Impact of Pre-Morbid Antidepressant Exposure on the Risk of Intracerebral Hemorrhage: The Florida Stroke Registry
Abstract only Antidepressants (AD), particularly selective serotonin reuptake inhibitors (SSRIs), are amongst the most frequently prescribed medications. Concerns have been raised regarding their potential increased risk of bleeding complications including intracerebral hemorrhage (ICH) as they are known to affect platelet function. In the large Florida Stroke Registry (FSR), we sought to determine if pre-morbid use of AD impacted the risk of ICH Methods: Data collected from Jan 2010-Jun 2023 in FSR, GWTG statewide stroke registry comprised of 170 hospitals in the state of Florida was used to identify ischemic (IS) and hemorrhagic stroke cases with and without prior use of AD. Multivariate regression with generalized estimating equations, were used to determine whether premorbid-AD use was associated with an increased risk of ICH vs. ischemic stroke Results: A total of 219,558 stroke cases were identified (mean age 70.26±14.45; 52% male), among those 14% had pre-morbid AD use (age 72.13±13.23, 39% male). Patients on pre-morbid AD (vs no AD) were more likely White (75% vs. 62%) female (61% vs. 46%), with higher rates of vascular risk factors [(HTN (83%), DM (40%), HLD (61%), prior TIA (39%)]. The percentage of ICH was 11% and 14% amongst AD users and non-AD users respectively. In a multivariate model adjusting by multiple covariates, prior use of AD was not associated with an increased likelihood of presenting with ICH as opposed to IS (OR=0.72, 0.42-1.21). In the sensitivity analysis of subgroups of patients with data regarding the class of AD (SSRIs, Non-SSRIs) (n=657) or prior antiplatelet or anticoagulant therapies (n=740) premorbid SSRI use (vs no AD use) was not associated with increase ICH risk (OR=1.39, 95%CI 0.81-2.38 and OR=0.84, 0.64-1.10) Discussion In this large registry-based study we did not find an association between prior use of AD and increased risk of ICH as opposed to IS. Additionally, our findings were consistent among stroke patients with prior use of either antiplatelet or anticoagulants. These findings challenge the prevailing literature notion that AD, particularly SSRIs are linked to an increased risk of hemorrhages of all type. However, clinicians should consider individual patient's presentation, comorbidities and preferences when prescribing A
Clinical impact of the first pass effect on clinical outcomes in patients with near or complete recanalization during mechanical thrombectomy for large vessel ischemic stroke
The first pass effect has been reported as a mechanical thrombectomy (MT) success metric in patients with large vessel occlusive stroke. We aimed to compare the clinical and neuroimagign outcomes of patients who had favorable recanalization (mTICI 2c or mTICI 3) achieved in one pass versus those requiring multiple passes.
In this "real-world" multicenter study, patients with mTICI 2c or 3 recanalization were identified from three prospectively collected stroke databases from January 2016 to December 2019. Clinical outcomes were a favorable functional outcome at 90 days (modified Rankin Scale score 0-2), and the rate of symptomatic intracranial hemorrhage (ICH) any ICH, and 90-day mortality.
Favorable recanalization was achieved in 390/664 (59%) of consecutive patients who underwent MT (age 71.2 ± 13.2 years, 188 [48.2%] women). This was achieved after a single thrombectomy pass (n = 290) or multiple thrombectomy passes (n = 100). The rate of favorable clinical outcome was higher (41% vs. 28 %, p = .02) in the first pass group with a continued trend on multivariate analysis that did not reaching statistical significance (OR 1.68 95% confidence interval [CI] 1.0-2.95, p = .07). Similarly, the odds of any ICH were significantly lower (OR 0.56 CI 0.32-0.97, p = .03). A similar trend of favorable clinical outcomes was noticed on subgroup analysis of patients with M1 occlusion (OR 1.81 CI 1.01-3.61, p = .08).
The first-pass reperfusion was associated with a trend toward favorable clinical outcome and lower rates of ICH. These data suggest that the first-pass effect should be the mechanical thrombectomy procedure goal
Anticoagulation Timing in Cardioembolic Stroke and Recurrent Event Risk.
OBJECTIVES: Guidelines recommend to initiate anticoagulation within 4-14 days after cardioembolic stroke. Data supporting this did not account for key factors potentially affecting the decision to initiate anticoagulation such as infarct size, hemorrhagic transformation, or high risk features on echocardiography. METHODS: We pooled data from stroke registries of 8 comprehensive stroke centers across the United States. We included consecutive patients admitted with ischemic stroke and atrial fibrillation. The primary predictor was timing of initiating anticoagulation (0-3 days, 4-14 days, or >14 days) and outcomes were recurrent stroke/TIA/systemic embolism, symptomatic intracerebral hemorrhage (sICH), and major extracranial hemorrhage (ECH) within 90 days. RESULTS: Among 2084 patients, 1289 met the inclusion criteria. The combined endpoint occurred in 10.1% (n = 130) subjects (87 ischemic events, 20 sICH, and 29 ECH). Overall, there was no significant difference in the composite endpoint between the three groups: 0-3 days [10.3% (64/617)], 4-14 days [(9.7%) 52/535)], >14 days [10.2% (14/137), p=0.933]. In adjusted models, patients started on anticoagulation between 4-14 days did not have a lower rate of sICH (vs. 0-3 days) (OR 1.49 95% CI 0.50 – 4.43) neither did they have a lower rate of recurrent ischemic events (vs. > 14 days) (OR 0.76 95% CI 0.36 – 1.62, p = 0.482). INTERPRETATION: In this multicenter real world cohort, the recommended (4-14 days) time frame to start oral anticoagulation was not associated with reduced ischemic and hemorrhagic outcomes. Randomized trials are required to determine the optimal timing of anticoagulation initiation
Early ischaemic and haemorrhagic complications after atrial fibrillation-related ischaemic stroke: analysis of the IAC study.
INTRODUCTION: Predictors of long-term ischemic and hemorrhagic complications in atrial fibrillation (AF) have been studied, but there is limited data on predictors of early ischemic and hemorrhagic complications after AF associated ischemic stroke. We sought to determine these predictors. METHODS: The Initiation of Anticoagulation after Cardioembolic stroke (IAC) study is a multicenter retrospective study across that pooled data from consecutive patients with ischemic stroke in the setting of AF from stroke registries across 8 comprehensive stroke centers in the United States. The co-primary outcomes were recurrent ischemic event (stroke/TIA/systemic arterial embolism) and delayed symptomatic intracranial hemorrhage (d-sICH) within 90 days. We performed univariate analyses and cox regression analyses including important predictors on univariate analyses to determine independent predictors of early ischemic events (stroke/TIA/systemic embolism) and d-sICH. RESULTS: Out of 2084 patients, 1520 patients qualified; 104 patients (6.8%) had recurrent ischemic events and 23 patients (1.5%) had d-sICH within 90 days from the index event. In cox-regression models, factors associated with a trend for recurrent ischemic events were prior stroke or TIA (HR 1.42, 0.96 – 2.10) and ipsilateral arterial stenosis with 50–99% narrowing (HR 1.54, 0.98 – 2.43). Those associated with sICH were female sex (HR 2.68, 1.06– 6.83), history of hyperlipidemia (HR 2.91, 1.08 – 7.84), and early hemorrhagic transformation (HR 5.35, 2.22 – 12.92). CONCLUSION: In patients with ischemic stroke and AF, predictors of d-sICH are different than those of recurrent ischemic events therefore recognizing these predictors may help inform early stroke versus d-sICH prevention strategies
Anticoagulation Type and Early Recurrence in Cardioembolic Stroke: The IAC Study.
BACKGROUND AND PURPOSE: In patients with acute ischemic stroke and atrial fibrillation (AF), treatment with low molecular weight heparin (LMWH) increases early hemorrhagic risk without reducing early recurrence and there is limited data comparing warfarin to direct oral anticoagulant (DOAC) therapy. We aim to compare the effects of the treatments above on the risk of 90-day recurrent ischemic events and delayed symptomatic intracranial hemorrhage (d-sICH). METHODS: We included consecutive patients with acute ischemic stroke and AF from the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study pooling data from stroke registries of 8 comprehensive stroke centers across the United States. We compared recurrent ischemic events and d-sICH between each of the following groups in separate cox-regression analyses: 1) DOAC versus warfarin and 2) Bridging with heparin/LMWH versus no bridging, adjusting for pertinent confounders to test these associations. RESULTS: We identified 1,289 patients who met the “bridging versus no bridging” analysis inclusion criteria and 1,251 patients who met the “DOAC versus warfarin” analysis inclusion criteria. In adjusted cox-regression models, bridging (versus no bridging) treatment was associated with a high risk of d-sICH (HR 2.74 95% CI 1.01 – 7.42) but a similar rate of recurrent ischemic events (HR 1.23 95% CI 0.63 – 2.40). Furthermore, DOAC (versus warfarin) treatment was associated with a lower risk of recurrent ischemic events (HR 0.51 95% CI 0.29 – 0.87) but not d-sICH (HR 0.57 95% CI 0.22 – 1.48). CONCLUSION: Our study suggests that patients with ischemic stroke and AF would benefit from the initiation of a DOAC without bridging therapy. Due to our study limitations, these findings should be interpreted with caution pending confirmation from large prospective studies
Factors associated with therapeutic anticoagulation status in patients with ischemic stroke and atrial fibrillation.
BACKGROUND AND PURPOSE: Understanding factors associated with ischemic stroke despite therapeutic anticoagulation is an important goal to improve stroke prevention strategies in patients with atrial fibrillation (AF). We aim to determine factors associated with therapeutic or supratherapeutic anticoagulation status at the time of ischemic stroke in patients with AF. METHODS: The Initiation of Anticoagulation after Cardioembolic stroke (IAC) study is a multicenter study pooling data from stroke registries of eight comprehensive stroke centers across the United States. Consecutive patients hospitalized with acute ischemic stroke in the setting of AF were included in the IAC cohort. For this study, we only included patients who reported taking warfarin at the time of the ischemic stroke. Patients not on anticoagulation and patients who reported use of a direct oral anticoagulant were excluded. Analyses were stratified based on therapeutic (INR ≥2) versus subtherapeutic (INR <2) anticoagulation status. We used binary logistic regression models to determine factors independently associated with anticoagulation status after adjustment for pertinent confounders. In particular, we sought to determine whether atherosclerosis with 50% or more luminal narrowing in an artery supplying the infarct (a marker for a competing atherosclerotic mechanism) and small stroke size (≤ 10 mL; implying a competing small vessel disease mechanism) related to anticoagulant status. RESULTS: Of the 2084 patients enrolled in the IAC study, 382 patients met the inclusion criteria. The mean age was 77.4 ± 10.9 years and 52.4% (200/382) were men. A total of 222 (58.1%) subjects presented with subtherapeutic INR. In adjusted models, small stroke size (OR 1.74 95% CI 1.10 – 2.76, p = 0.019) and atherosclerosis with 50% or more narrowing in an artery supplying the infarct (OR 1.96 95% CI 1.06 – 3.63, p = 0.031) were independently associated with INR ≥2 at the time of their index stroke. CONCLUSION: Small stroke size (≤ 10 ml) and ipsilateral atherosclerosis with 50% or more narrowing may indicate a competing stroke mechanism. There may be important opportunities to improve stroke prevention strategies for patients with AF by targeting additional ischemic stroke mechanisms to improve patient outcomes