Sex Differences in rt-PA Utilization at Hospitals Treating Stroke: The National Inpatient Sample.

BACKGROUND AND PURPOSE: Sex and race disparities in recombinant tissue plasminogen activator (rt-PA) use have been reported. We sought to explore sex and race differences in the utilization of rt-PA at primary stroke centers (PSCs) compared to non-PSCs across the US. METHODS: Data from the National (Nationwide) Inpatient Sample (NIS) 2004-2010 was utilized to assess sex differences in treatment for ischemic stroke in PSCs compared to non-PSCs. RESULTS: There were 304,152 hospitalizations with a primary diagnosis of ischemic stroke between 2004 and 2010 in the analysis: 75,160 (24.7%) patients were evaluated at a PSC. A little over half of the patients evaluated at PSCs were female (53.8%). A lower proportion of women than men received rt-PA at both PSCs (6.8 vs. 7.5%, p \u3c 0.001) and non-PSCs (2.3 vs. 2.8%, p \u3c 0.001). After adjustment for potential confounders the odds of being treated with rt-PA remained lower for women regardless of presentation to a PSC (OR 0.87, 95% CI 0.81-0.94) or non-PSC (OR 0.88, 95% CI 0.82-0.94). After stratifying by sex and race, the lowest absolute treatment rates were observed in black women (4.4% at PSC, 1.9% at non-PSC). The odds of treatment, relative to white men, was however lowest for white women (PSC OR = 0.85, 95% CI 0.78-0.93; non-PSC OR = 0.80, 95% CI 0.75-0.85). In the multivariable model, sex did not modify the effect of PSC certification on rt-PA utilization (p-value for interaction = 0.58). CONCLUSION: Women are less likely to receive rt-PA than men at both PSCs and non-PSCs. Absolute treatment rates are lowest in black women, although the relative difference in men and women was greatest for white women

Mnemonic Monitoring in Anosognosia for Memory Loss

Objective: Anosognosia, or unawareness, for memory loss has been proposed to underlie cognitive functions such as memory and executive function. However, there is an inconsistent association between these constructs. Recent studies have shown that compromise ongoing self-monitoring of one’s memory associates with anosognosia for memory loss. Yet to date it is unclear which memory monitoring mechanisms are impaired in these patients. In this study, we examined the extent to which temporal monitoring or orbitofrontal reality filtering (e.g., ability to monitor the temporal relevance of a memory) and source monitoring (e.g., the ability to distinguish which memories stem from internal as opposed to external sources) are associated with awareness of memory deficits. Methods: A total of 35 patients (M=69 years; M=14 years of education) with memory difficulties following a stroke were recruited from outpatient clinics. Patients were assessed with measures of self-awareness of memory difficulties, cognitive abilities and two experimental paradigms assessing source and temporal monitoring. Results and conclusion: Results showed that patients unaware of their memory difficulties were more likely to externalize the source of their memories. Specifically, those unaware of their deficits were more likely to assign an external source to memories that were internally produced (e.g., imagined). No differences were observed in relation to temporal monitoring between patients aware and unaware of their deficits. This study informs current theoretical models of self-awareness of memory loss. Future studies should attempt to replicate these findings and explore different memory monitoring mechanisms in relation to anosognosia for memory loss

Anosognosia for prospective and retrospective memory deficits: assessment and theoretical considerations

Objective: Patients who suffer from memory loss following an Acquired Brain Injury (ABI) may also suffer from anosognosia, or unawareness of their memory loss. How we define and measure anosognosia can have critical implications for its study and clinical assessment. Commonly used measures often lack standardization and reliability checks for responses. Moreover, these methods rely heavily on cognitive abilities (e.g., language abilities) that are often affected after brain injury. The aim of this study is to elucidate how to best conceptualize and detect anosognosia for memory loss by introducing a new method of assessment, the Visual-Analogue Test for Anosognosia for memory impairment (VATAmem). Methods: A total of 51 patients (M= 61 years; M= 13 years of education) with memory difficulties following ABI were recruited from outpatient clinics. A total of 73 informants were also recruited (M= 51 years old; M= 13 years of education). Both patients and informants evaluated the severity of patients’ everyday memory mistakes on the VATAmem, for prospective and retrospective memory deficits by using visual analogue scales, vignettes and check questions to ensure reliability. Results and conclusion: A total of 30% of the patients were deemed unaware of their memory deficits. Patients were less aware of their prospective (29%) than their retrospective memory difficulties (18%). The new method of assessment provided by the VATAmem reduced possible false positives and enhanced reliability. We conclude that careful consideration of methodology is a key step to interpreting anosognosia findings within a theoretical framewor

Dementia and Stroke Risk Associated with Brain Artery Luminal Diameters

Background: It is unclear whether brain artery diameters measured on conventional T2-weighted brain MRI images relate to dementia and stroke outcomes across distinct populations. We aimed this study to evaluate the association of T2-weighted brain artery luminal diameters with dementia and stroke in three distinct population‑based studies. Methods: Three longitudinal population-based studies with 8420 adults \u3e40 years old (Northern Manhattan Study [NOMAS] from the United States, and the Rotterdam Study [RS], from the Netherlands, and Three-City, from France) with brain MRI scans obtained between 1999 and 2015. The median follow-up time for clinical events ranged between 7 and 12.5 years. We tested our hypothesis in each cohort separately due to local data‑sharing regulations. The exposure variable was brain carotid and basilar artery luminal diameters measured on MRI axial T2‑weighted scans. Multivariable hazard ratios (HRs) and their 95% confidence intervals (CI) expressed the risk of dementia and stroke (primary outcomes) associated with the lowest (\u3c5th) and highest (\u3e95th) percentiles of the rank‑normalized brain artery diameters compared to a reference group defined as the diameters distributed between the 5th and 95th percentiles. Secondary outcomes included total and vascular mortality, and fatal and nonfatal cardiovascular and coronary end points. Results: Among the three cohorts (mean age ranged from 65 to 73 y, ≥57% women), 335 participants developed dementia and 331 strokes. Compared with the reference group, participants with arterial diameters \u3e95th percentile had a higher risk of dementia (HR range 1.15-4.50) and any stroke (HR range 1.29-2.03). For secondary outcomes, participants with arterial diameters \u3e95th percentile had a consistent higher risk of coronary outcomes, vascular mortality and a composite of any vascular events. The results were less supportive of a higher risk of events among participants with arterial diameters \u3c5th percentile except for vascular mortality. Conclusions: Individuals with dilated brain arteries are at higher risk of dementia and vascular events. Our findings were consistency across distinct populations in spite of using a non-enhanced, conventional T2-weighted MRI sequence. Understanding the underlying physiopathology of the reported associations, particularly with dementia and stroke, might reveal novel vascular contributions to dementi

Maternal Morbidity Outcomes in Idiopathic Moyamoya Syndrome in New York State

Background: Pregnancy is associated with an increased risk of stroke in young women. Idiopathic moyamoya syndrome (IMMS) is a rare condition characterized by progressive narrowing of large cerebral arteries resulting in flimsy collaterals prone to rupture or thrombosis. Data are limited on pregnancy outcomes in women with IMMS. We hypothesized that IMMS would be associated with increased pregnancy morbidity, including stroke. Conclusion: Pregnancies within 1 year prior or any time after IMMS diagnosis did not have increased maternal morbidity compared to unexposed pregnancies after adjusting for age and clustering of women with multiple pregnancies. Prospective studies are needed to better characterize increased maternal risks for women with moyamoya syndrome and develop preventive strategies

Criteria for evaluation of novel markers of cardiovascular risk: A scientific statement from the American Heart Association

There is increasing interest in utilizing novel markers of cardiovascular disease risk, and consequently, there is a need to assess the value of their use. This scientific statement reviews current concepts of risk evaluation and proposes standards for the critical appraisal of risk assessment methods. An adequate evaluation of a novel risk marker requires a sound research design, a representative at-risk population, and an adequate number of outcome events. Studies of a novel marker should report the degree to which it adds to the prognostic information provided by standard risk markers. No single statistical measure provides all the information needed to assess a novel marker, so measures of both discrimination and accuracy should be reported. The clinical value of a marker should be assessed by its effect on patient management and outcomes. In general, a novel risk marker should be evaluated in several phases, including initial proof of concept, prospective validation in independent populations, documentation of incremental information when added to standard risk markers, assessment of effects on patient management and outcomes, and ultimately, cost-effectiveness

Arteriopathy diagnosis in childhood arterial ischemic stroke: results of the vascular effects of infection in pediatric stroke study.

Background and purposeAlthough arteriopathies are the most common cause of childhood arterial ischemic stroke, and the strongest predictor of recurrent stroke, they are difficult to diagnose. We studied the role of clinical data and follow-up imaging in diagnosing cerebral and cervical arteriopathy in children with arterial ischemic stroke.MethodsVascular effects of infection in pediatric stroke, an international prospective study, enrolled 355 cases of arterial ischemic stroke (age, 29 days to 18 years) at 39 centers. A neuroradiologist and stroke neurologist independently reviewed vascular imaging of the brain (mandatory for inclusion) and neck to establish a diagnosis of arteriopathy (definite, possible, or absent) in 3 steps: (1) baseline imaging alone; (2) plus clinical data; (3) plus follow-up imaging. A 4-person committee, including a second neuroradiologist and stroke neurologist, adjudicated disagreements. Using the final diagnosis as the gold standard, we calculated the sensitivity and specificity of each step.ResultsCases were aged median 7.6 years (interquartile range, 2.8-14 years); 56% boys. The majority (52%) was previously healthy; 41% had follow-up vascular imaging. Only 56 (16%) required adjudication. The gold standard diagnosis was definite arteriopathy in 127 (36%), possible in 34 (9.6%), and absent in 194 (55%). Sensitivity was 79% at step 1, 90% at step 2, and 94% at step 3; specificity was high throughout (99%, 100%, and 100%), as was agreement between reviewers (κ=0.77, 0.81, and 0.78).ConclusionsClinical data and follow-up imaging help, yet uncertainty in the diagnosis of childhood arteriopathy remains. This presents a challenge to better understanding the mechanisms underlying these arteriopathies and designing strategies for prevention of childhood arterial ischemic stroke

Risk of Recurrent Arterial Ischemic Stroke in Childhood: A Prospective International Study.

Background and purposePublished cohorts of children with arterial ischemic stroke (AIS) in the 1990s to early 2000s reported 5-year cumulative recurrence rates approaching 20%. Since then, utilization of antithrombotic agents for secondary stroke prevention in children has increased. We sought to determine rates and predictors of recurrent stroke in the current era.MethodsThe Vascular Effects of Infection in Pediatric Stroke (VIPS) study enrolled 355 children with AIS at 37 international centers from 2009 to 2014 and followed them prospectively for recurrent stroke. Index and recurrent strokes underwent central review and confirmation, as well as central classification of causes of stroke, including arteriopathies. Other predictors were measured via parental interview or chart review.ResultsOf the 355 children, 354 survived their acute index stroke, and 308 (87%) were treated with an antithrombotic medication. During a median follow-up of 2.0 years (interquartile range, 1.0-3.0), 40 children had a recurrent AIS, and none had a hemorrhagic stroke. The cumulative stroke recurrence rate was 6.8% (95% confidence interval, 4.6%-10%) at 1 month and 12% (8.5%-15%) at 1 year. The sole predictor of recurrence was the presence of an arteriopathy, which increased the risk of recurrence 5-fold when compared with an idiopathic AIS (hazard ratio, 5.0; 95% confidence interval, 1.8-14). The 1-year recurrence rate was 32% (95% confidence interval, 18%-51%) for moyamoya, 25% (12%-48%) for transient cerebral arteriopathy, and 19% (8.5%-40%) for arterial dissection.ConclusionsChildren with AIS, particularly those with arteriopathy, remain at high risk for recurrent AIS despite increased utilization of antithrombotic agents. Therapies directed at the arteriopathies themselves are needed