Clinical dilemmas in acute neurological disorders

This thesis introduces the evolving landscape of acute neurology and the challenges it presents to clinicians in the emergency department (ED).In Chapter 2, the focus is on mild traumatic brain injury (mTBI) in patients on anticoagulation therapy. The study, involving 905 patients, reveals that delayed intracranial hemorrhage within 24 hours is very rare after a normal cranial CT, suggesting that routine hospitalization may be unnecessary.Chapter 3 delves into alcohol intoxication as a stroke mimic, especially in posterior circulation cases. The study, involving 974 patients, emphasizes considering measuring blood ethanol levels in patients with a possible stroke of the posterior circulation presenting after working hours. Nevertheless, elevated blood ethanol levels should not withhold clinicians from administering reperfusion therapy.Chapter 4 explores the association between low blood pressure and outcomes after acute ischemic stroke (AIS). Analyzing data from 2124 patients, the study finds that low systolic blood pressure is linked to increased in-hospital mortality and complications, urging clinicians to investigate potential underlying conditions.In Chapter 5, the focus shifts to AIS patients with active cancer undergoing endovascular treatment. The study, involving 2583 patients, indicates that despite technical success, those with active cancer experience significantly worse outcomes and an increased risk of recurrent stroke after EVT. Still, about a quarter of the patients regained functional independence, and the risk of other complications was not increased.This thesis collectively highlights the importance of nuanced decision-making in acute neurology, offering insights into specific clinical dilemmas and proposing considerations for optimized patient care

Het werk van Wibo van Rossum - een bloemlezing

This article is about the work of Wibo van Rossum who passed away in April 2018. Trained as a legal anthropologist he has conducted empirical research on the administration of justice in the Netherlands for many years. This anthology is about four research reports he produced and many articles he has written in two decades. This article provides an academic as well as a practical review of his work

Het werk van Wibo van Rossum - een bloemlezing

This article is about the work of Wibo van Rossum who passed away in April 2018. Trained as a legal anthropologist he has conducted empirical research on the administration of justice in the Netherlands for many years. This anthology is about four research reports he produced and many articles he has written in two decades. This article provides an academic as well as a practical review of his work

Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke: A MR CLEAN Registry Substudy

BACKGROUND AND OBJECTIVES: To explore clinical and safety outcomes of patients with acute ischemic stroke (AIS) and active cancer after endovascular treatment (EVT). METHODS: Using data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry, we compared patients with active cancer (defined as cancer diagnosed within 12 months before stroke, metastatic disease, or current cancer treatment) to patients without cancer. Outcomes were 90-day modified Rankin Scale (mRS) score, mortality, successful reperfusion (expanded Treatment in Cerebral Infarction score >/=2b), symptomatic intracranial hemorrhage (sICH), and recurrent stroke. Subgroup analyses were performed in patients with a prestroke mRS score of 0 or 1 and according to treatment setting (curative or palliative). Analyses were adjusted for prognostic variables. RESULTS: Of 2,583 patients who underwent EVT, 124 (4.8%) had active cancer. They more often had prestroke disability (mRS score >/=2: 34.1% vs 16.6%). The treatment setting was palliative in 25.3% of the patients. There was a shift toward worse functional outcome at 90 days in patients with active cancer (adjusted common odds ratio [acOR] 2.2, 95% confidence interval [CI] 1.5-3.2). At 90 days, patients with active cancer were less often independent (mRS score 0-2: 22.6% vs 42.0%, adjusted OR [aOR] 0.5, 95% CI 0.3-0.8) and more often dead (52.2% vs 26.5%, aOR 3.2, 95% CI 2.1-4.9). Successful reperfusion (67.8% vs 60.5%, aOR 1.4, 95% CI 1.0-2.1) and sICH rates (6.5% vs 5.9%, aOR 1.1, 95% CI 0.5-2.3) did not differ. Recurrent stroke within 90 days was more common in patients with active cancer (4.0% vs 1.3%, aOR 3.1, 95% CI 1.2-8.1). The sensitivity analysis of patients with a prestroke mRS score of 0 or 1 showed that patients with active cancer still had a worse outcome at 90 days (acOR 1.9, 95% CI 1.2-3.0). Patients with active cancer in a palliative treatment setting regained functional independence less often compared to patients in a curative setting (18.2% vs 32.1%), and mortality was higher (81.8% vs 39.3%). DISCUSSION: Despite similar technical success, patients with active cancer had significantly worse outcomes after EVT for AIS. Moreover, they had an increased risk of recurrent stroke. Nevertheless, about a quarter of the patients regained functional independence, and the risk of other complications, most notably sICH, was not increased. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that patients with active cancer undergoing EVT for AIS have worse functional outcomes at 90 days compared to those without active cancer

Clinical outcome after endovascular treatment in patients with active cancer and ischemic stroke

Background and Objectives To explore clinical and safety outcomes of patients with acute ischemic stroke (AIS) and active cancer after endovascular treatment (EVT). Methods Using data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry, we compared patients with active cancer (defined as cancer diagnosed within 12 months before stroke, metastatic disease, or current cancer treatment) to patients without cancer. Outcomes were 90-day modified Rankin Scale (mRS) score, mortality, successful reperfusion (expanded Treatment in Cerebral Infarction score ≥2b), symptomatic intracranial hemorrhage (sICH), and recurrent stroke. Subgroup analyses were performed in patients with a prestroke mRS score of 0 or 1 and according to treatment setting (curative or palliative). Analyses were adjusted for prognostic variables. Results Of 2,583 patients who underwent EVT, 124 (4.8%) had active cancer. They more often had prestroke disability (mRS score ≥2: 34.1% vs 16.6%). The treatment setting was palliative in 25.3% of the patients. There was a shift toward worse functional outcome at 90 days in patients with active cancer (adjusted common odds ratio [acOR] 2.2, 95% confidence interval [CI] 1.5–3.2). At 90 days, patients with active cancer were less often independent (mRS score 0–2: 22.6% vs 42.0%, adjusted OR [aOR] 0.5, 95% CI 0.3–0.8) and more often dead (52.2% vs 26.5%, aOR 3.2, 95% CI 2.1–4.9). Successful reperfusion (67.8% vs 60.5%, aOR 1.4, 95% CI 1.0–2.1) and sICH rates (6.5% vs 5.9%, aOR 1.1, 95% CI 0.5–2.3) did not differ. Recurrent stroke within 90 days was more common in patients with active cancer (4.0% vs 1.3%, aOR 3.1, 95% CI 1.2–8.1). The sensitivity analysis of patients with a prestroke mRS score of 0 or 1 showed that patients with active cancer still had a worse outcome at 90 days (acOR 1.9, 95% CI 1.2–3.0). Patients with active cancer in a palliative treatment setting regained functional independence less often compared to patients in a curative setting (18.2% vs 32.1%), and mortality was higher (81.8% vs 39.3%). Discussion Despite similar technical success, patients with active cancer had significantly worse outcomes after EVT for AIS. Moreover, they had an increased risk of recurrent stroke. Nevertheless, about a quarter of the patients regained functional independence, and the risk of other complications, most notably sICH, was not increased

Clinical outcome after endovascular treatment in patients with active cancer and ischemic stroke: a MR CLEAN registry substudy

Background and Objectives: To explore clinical and safety outcomes of patients with acute ischemic stroke (AIS) and active cancer after endovascular treatment (EVT). Methods: Using data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry, we compared patients with active cancer (defined as cancer diagnosed within 12 months before stroke, metastatic disease, or current cancer treatment) to patients without cancer. Outcomes were 90-day modified Rankin Scale (mRS) score, mortality, successful reperfusion (expanded Treatment in Cerebral Infarction score >= 2b), symptomatic intracranial hemorrhage (sICH), and recurrent stroke. Subgroup analyses were performed in patients with a prestroke mRS score of 0 or 1 and according to treatment setting (curative or palliative). Analyses were adjusted for prognostic variables. Results: Of 2,583 patients who underwent EVT, 124 (4.8%) had active cancer. They more often had prestroke disability (mRS score >= 2: 34.1% vs 16.6%). The treatment setting was palliative in 25.3% of the patients. There was a shift toward worse functional outcome at 90 days in patients with active cancer (adjusted common odds ratio [acOR] 2.2, 95% confidence interval [CI] 1.5-3.2). At 90 days, patients with active cancer were less often independent (mRS score 0-2: 22.6% vs 42.0%, adjusted OR [aOR] 0.5, 95% CI 0.3-0.8) and more often dead (52.2% vs 26.5%, aOR 3.2, 95% CI 2.1-4.9). Successful reperfusion (67.8% vs 60.5%, aOR 1.4, 95% CI 1.0-2.1) and sICH rates (6.5% vs 5.9%, aOR 1.1, 95% CI 0.5-2.3) did not differ. Recurrent stroke within 90 days was more common in patients with active cancer (4.0% vs 1.3%, aOR 3.1, 95% CI 1.2-8.1). The sensitivity analysis of patients with a prestroke mRS score of 0 or 1 showed that patients with active cancer still had a worse outcome at 90 days (acOR 1.9, 95% CI 1.2-3.0). Patients with active cancer in a palliative treatment setting regained functional independence less often compared to patients in a curative setting (18.2% vs 32.1%), and mortality was higher (81.8% vs 39.3%). Discussion: Despite similar technical success, patients with active cancer had significantly worse outcomes after EVT for AIS. Moreover, they had an increased risk of recurrent stroke. Nevertheless, about a quarter of the patients regained functional independence, and the risk of other complications, most notably sICH, was not increased. Classification of Evidence: This study provides Class I evidence that patients with active cancer undergoing EVT for AIS have worse functional outcomes at 90 days compared to those without active cancer.</p