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1. Associations of Early Systolic Blood Pressure Control and Outcome After Thrombolysis-Eligible Acute Ischemic Stroke: Results From the ENCHANTED Study

Author

Wang, X, Minhas, JS, Moullaali, TJ, Di Tanna, GL, Lindley, R, Chen, X, Arima, H, Chen, G, Delcourt, C, Bath, PM, Broderick, JP, Demchuk, AM, Donnan, GA, Durham, AC, Lavados, PM, Lee, T-H, Levi, C, Martins, SO, Olavarria, VV, Pandian, JD, Parsons, MW, Pontes-Neto, OM, Ricci, S, Sato, S, Sharma, VK, Silva, F, Thang, NH, Wang, J-G, Woodward, M, Chalmers, J, Song, L, Anderson, CS, Robinson, TG, Wang, X, Minhas, JS, Moullaali, TJ, Di Tanna, GL, Lindley, R, Chen, X, Arima, H, Chen, G, Delcourt, C, Bath, PM, Broderick, JP, Demchuk, AM, Donnan, GA, Durham, AC, Lavados, PM, Lee, T-H, Levi, C, Martins, SO, Olavarria, VV, Pandian, JD, Parsons, MW, Pontes-Neto, OM, Ricci, S, Sato, S, Sharma, VK, Silva, F, Thang, NH, Wang, J-G, Woodward, M, Chalmers, J, Song, L, Anderson, CS, and Robinson, TG

Abstract

BACKGROUND AND PURPOSE: In thrombolysis-eligible patients with acute ischemic stroke, there is uncertainty over the most appropriate systolic blood pressure (SBP) lowering profile that provides an optimal balance of potential benefit (functional recovery) and harm (intracranial hemorrhage). We aimed to determine relationships of SBP parameters and outcomes in thrombolyzed acute ischemic stroke patients. METHODS: Post hoc analyzes of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study), a partial-factorial trial of thrombolysis-eligible and treated acute ischemic stroke patients with high SBP (150-180 mm Hg) assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) alteplase and intensive (target SBP, 130-140 mm Hg) or guideline-recommended (target SBP <180 mm Hg) treatment. All patients were followed up for functional status and serious adverse events to 90 days. Logistic regression models were used to analyze 3 SBP summary measures postrandomization: attained (mean), variability (SD) in 1-24 hours, and magnitude of reduction in 1 hour. The primary outcome was a favorable shift on the modified Rankin Scale. The key safety outcome was any intracranial hemorrhage. RESULTS: Among 4511 included participants (mean age 67 years, 38% female, 65% Asian) lower attained SBP and smaller SBP variability were associated with favorable shift on the modified Rankin Scale (per 10 mm Hg increase: odds ratio, 0.76 [95% CI, 0.71-0.82]; P<0.001 and 0.86 [95% CI, 0.76-0.98]; P=0.025) respectively, but not for magnitude of SBP reduction (0.98, [0.93-1.04]; P=0.564). Odds of intracranial hemorrhage was associated with higher attained SBP and greater SBP variability (1.18 [1.06-1.31]; P=0.002 and 1.34 [1.11-1.62]; P=0.002) but not with magnitude of SBP reduction (1.05 [0.98-1.14]; P=0.184). CONCLUSIONS: Attaining early and consistent low levels in SBP <140 mm Hg, even as low as 110 to 120 mm Hg, over 24 hours is associated with better outcomes in thrombolyzed

Published
2022

2. Oxygen desaturation and adverse outcomes in acute stroke: Secondary analysis of the HeadPoST study

Author

Ouyang, M, Roffe, C, Billot, L, Song, L, Wang, X, Muñoz-Venturelli, P, Lavados, PM, Robinson, T, Middleton, S, Olavarría, VV, Watkins, CL, Lee, TH, Brunser, AM, Pontes-Neto, OM, Hackett, ML, Anderson, CS, Ouyang, M, Roffe, C, Billot, L, Song, L, Wang, X, Muñoz-Venturelli, P, Lavados, PM, Robinson, T, Middleton, S, Olavarría, VV, Watkins, CL, Lee, TH, Brunser, AM, Pontes-Neto, OM, Hackett, ML, and Anderson, CS

Abstract

Objective: Uncertainty exists over the prognostic significance of low arterial oxygen saturation (SaO2) in acute stroke. We aimed to determine the strength of association of SaO2 and adverse outcomes among participants of the international Head Positioning in acute Stroke Trial (HeadPoST). Methods: Post-hoc analyzes of HeadPoST, a pragmatic cluster-crossover randomized trial of lying flat versus sitting up head positioning in 11,093 patients (age ≥18 years) with acute stroke at 114 hospitals in 9 countries during 2015–2016. Associations of the lowest recorded SaO2 level, as a continuous measure and as a cut-point for desaturation (SaO2 <93%), in the first 24 h and clinical outcomes of death or dependency (modified Rankin scale [mRS] scores 3–6) and any serious adverse event (SAE) at 90 days, were assessed in generalized linear mixed models adjusted for baseline and in-hospital management confounders. Results: There was an inverse J-shaped association between SaO2 and death or dependency, with a nadir for optimal outcome at 96–97%. Patients with SaO2 desaturation were older, and had greater neurological impairment, premorbid disability and cardiorespiratory disease. Desaturation was not clearly associated with death or dependency (adjusted odds ratio [aOR] 1.19, 95% confidence interval [CI] 0.95–1.48) but was with SAEs (aOR 1.34, 95% CI 1.07–1.68), without heterogeneity by head position, cardiac-respiratory comorbidity, or other pre-specified subgroups. Conclusions: Any change in SaO2 outside of 96–97% is associated with poorer outcome after acute stroke. Clinical trial registration: HeadPoST is registered at ClinicalTrials.gov (NCT02162017).

Published
2021

3. Lowblood pressure and adverse outcomes in acute stroke:HeadPoSTstudy explanations

Author

Ouyang, M, Munoz-Venturelli, P, Billot, L, Wang, X, Song, L, Arima, H, Lavados, PM, Hackett, ML, Olavarria, VV, Brunser, A, Middleton, S, Pontes-Neto, OM, Lee, TH, Watkins, CL, Robinson, T, Anderson, CS, Ouyang, M, Munoz-Venturelli, P, Billot, L, Wang, X, Song, L, Arima, H, Lavados, PM, Hackett, ML, Olavarria, VV, Brunser, A, Middleton, S, Pontes-Neto, OM, Lee, TH, Watkins, CL, Robinson, T, and Anderson, CS

Abstract

Objective: As uncertainties exist over underlying causes, we aimed to define the characteristics and prognostic significance of low blood pressure (BP) early after the onset of acute stroke. Methods: Post hoc analyzes of the international Head Positioning in acute Stroke Trial (HeadPoST), a pragmatic cluster-crossover randomized trial of lying flat versus sitting up in stroke patients from nine countries during 2015- 2016. Associations of baseline BP and death or dependency [modified Rankin scale (mRS) scores 3-6] and serious adverse events (SAEs) at 90 days were assessed in generalized linear mixed models with adjustment for multiple confounders. SBP and DBP was analysed as continuous measures fitted with a cubic spline, and as categorical measures with low (<10th percentile) and high (-140 and -90 mmHg, respectively) levels compared with a normal range (-10th percentile; 120-139 and 70- 89 mmHg, respectively). Results: Among 11 083 patients (mean age 68 years, 39.9% women) with baseline BP values, 7.2 and 11.7% had low SBP (<120 mmHg) and DBP (<70 mmHg), respectively. Patients with low SBP were more likely to have preexisting cardiac and ischemic stroke and functional impairment, and to present earlier with more severe neurological impairment than other patients. Nonlinear 'Jshaped' relationships of BP and poor outcome were apparent: Compared with normal SBP, those with low SBP had worse functional outcome (adjusted odds ratio 1.27, 95% confidence interval 1.02-1.58) and more SAEs, particularly cardiac events, with adjustment for potential confounders to minimize reverse causation. The findings were consistent for DBP and were stronger for ischemic rather than hemorrhagic stroke. Conclusion: The prognostic significance of low BP on poor outcomes in acute stroke was not explained by reverse causality from preexisting cardiovascular disease, and propensity towards greater neurological deficits and cardiac events. These findings provide support for the hypothesis tha

Published
2021

4. Validation of the simplified modified Rankin scale for stroke trials: Experience from the ENCHANTED alteplase-dose arm

Author

Chen, X, Li, J, Anderson, CS, Lindley, RI, Hackett, ML, Robinson, T, Lavados, PM, Wang, X, Arima, H, Chalmers, J, Delcourt, C, Chen, X, Li, J, Anderson, CS, Lindley, RI, Hackett, ML, Robinson, T, Lavados, PM, Wang, X, Arima, H, Chalmers, J, and Delcourt, C

Abstract

Background and aims: The structured, simplified modified Rankin scale questionnaire (smRSq) may increase reliability over the interrogative approach to scoring the modified Rankin scale (mRS) in acute stroke research and practice. During the conduct of the alteplase-dose arm of the international ENhanced Control of Hypertension ANd Thrombolysis StrokE stuDy (ENCHANTED), we had an opportunity to compare each of these approaches to outcome measurement. Methods: Baseline demographic data were recorded together with the National Institutes of Health Stroke Scale (NIHSS). Follow-up measures obtained at 90 days included mRS, smRSq, and the 5-Dimension European Quality of life scale (EQ-5D). Agreements between smRSq and mRS were assessed with the Kappa statistic. Multiple logistic regression was used to identify baseline predictors of Day 90 smRSq and mRS scores. Treatment effects, based on Day 90 smRSq/mRS scores, were tested in logistic and ordinal logistic regression models. Results: SmRSq and mRS scores had good agreement (weighted Kappa 0.79, 95% confidence interval (CI) 0.78–0.81), while variables of age, atrial fibrillation, diabetes mellitus, pre-morbid mRS (1 vs. 0), baseline NIHSS scores, and imaging signs of cerebral ischemia, similarly predicted their scores. Odds ratios for death or disability, and ordinal shift, 90-day mRS scores using smRSq were 1.05 (95% CI 0.91–1.20; one-sided P = 0.23 for non-inferiority) and 0.98 (95% CI 0.87–1.11; P = 0.02 for non-inferiority), similar to those using mRS. Conclusions: This study demonstrates the utility of the smRSq in a large, ethnically diverse clinical trial population. Scoring of the smRSq shows adequate agreement with the standard mRS, thus confirming it is a reliable, valid, and useful alternative measure of functional status after acute ischemic stroke. Clinical Trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01422616.

Published
2021

5. Prognostic significance of early urinary catheterization after acute stroke: Secondary analyses of the international HeadPoST trial

Author

Ouyang, M, Billot, L, Song, L, Wang, X, Roffe, C, Arima, H, Lavados, PM, Hackett, ML, Olavarría, VV, Muñoz-Venturelli, P, Middleton, S, Pontes-Neto, OM, Lee, TH, Watkins, CL, Robinson, TG, Anderson, CS, Ouyang, M, Billot, L, Song, L, Wang, X, Roffe, C, Arima, H, Lavados, PM, Hackett, ML, Olavarría, VV, Muñoz-Venturelli, P, Middleton, S, Pontes-Neto, OM, Lee, TH, Watkins, CL, Robinson, TG, and Anderson, CS

Abstract

Background: An indwelling urinary catheter (IUC) is often inserted to manage bladder dysfunction, but its impact on prognosis is uncertain. We aimed to determine the association of IUC use on clinical outcomes after acute stroke in the international, multi-center, cluster crossover, Head Positioning in Acute Stroke Trial (HeadPoST). Methods: Data were analyzed on HeadPoST participants (n = 11,093) randomly allocated to the lying-flat or sitting-up head position. Binomial, logistic regression, hierarchical mixed models were used to determine associations of early insertion of IUC within seven days post-randomization and outcomes of death or disability (defined as “poor outcome,” scores 3–6 on the modified Rankin scale) and any urinary tract infection at 90 days with adjustment of baseline and post-randomization management covariates. Results: Overall, 1167 (12%) patients had an IUC, but the frequency and duration of use varied widely across patients in different regions. IUC use was more frequent in older patients, and those with vascular comorbidity, greater initial neurological impairment (on the National Institutes of Health Stroke Scale), and intracerebral hemorrhage as the underlying stroke type. IUC use was independently associated with poor outcome (adjusted odds ratio (aOR): 1.40, 95% confidence interval (CI): 1.13–1.74), but not with urinary tract infection after adjustment for antibiotic treatment and stroke severity at hospital separation (aOR: 1.13, 95% CI: 0.59–2.18). The number exposed to IUC for poor outcome was 13. Conclusions: IUC use is associated with a poor outcome after acute stroke. Further studies are required to inform appropriate use of IUC.

Published
2021

6. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

Author

Feigin, VL, Stark, BA, Johnson, CO, Roth, GA, Bisignano, C, Abady, GG, Abbasifard, M, Abbasi-Kangevari, M, Abd-Allah, F, Abedi, V, Abualhasan, A, Abu-Rmeileh, NM, Abushouk, A, Adebayo, OM, Agarwal, G, Agasthi, P, Ahinkorah, BO, Ahmad, S, Ahmadi, S, Salih, YA, Aji, B, Akbarpour, S, Akinyemi, RO, Al Hamad, H, Alahdab, F, Alif, SM, Alipour, V, Aljunid, SM, Almustanyir, S, Al-Raddadi, RM, Salman, RA-S, Alvis-Guzman, N, Ancuceanu, R, Anderlini, D, Anderson, JA, Ansar, A, Antonazzo, IC, Arabloo, J, Arnlov, J, Artanti, KD, Aryan, Z, Asgari, S, Ashraf, T, Athar, M, Atreya, A, Ausloos, M, Baig, AA, Baltatu, OC, Banach, M, Barboza, MA, Barker-Collo, SL, Barnighausen, TW, Barone, MTU, Basu, S, Bazmandegan, G, Beghi, E, Beheshti, M, Bejot, Y, Bell, AW, Bennett, DA, Bensenor, IM, Bezabhe, WM, Bezabih, YM, Bhagavathula, AS, Bhardwaj, P, Bhattacharyya, K, Bijani, A, Bikbov, B, Birhanu, MM, Boloor, A, Bonny, A, Brauer, M, Brenner, H, Bryazka, D, Butt, ZA, dos Santos, FLC, Campos-Nonato, IR, Cantu-Brito, C, Carrero, JJ, Castaneda-Orjuela, CA, Catapano, AL, Chakraborty, PA, Charan, J, Choudhari, SG, Chowdhury, EK, Chu, D-T, Chung, S-C, Colozza, D, Costa, VM, Costanzo, S, Criqui, MH, Dadras, O, Dagnew, B, Dai, X, Dalal, K, Damasceno, AAM, D'Amico, E, Dandona, L, Dandona, R, Gela, JD, Davletov, K, De La Cruz-Gongora, V, Desai, R, Dhamnetiya, D, Dharmaratne, SD, Dhimal, ML, Dhimal, M, Diaz, D, Dichgans, M, Dokova, K, Doshi, R, Douiri, A, Duncan, BB, Eftekharzadeh, S, Ekholuenetale, M, El Nahas, N, Elgendy, IY, Elhadi, M, El-Jaafary, S, Endres, M, Endries, AY, Erku, DA, Faraon, EJA, Farooque, U, Farzadfar, F, Feroze, AH, Filip, I, Fischer, F, Flood, D, Gad, MM, Gaidhane, S, Gheshlagh, RG, Ghashghaee, A, Ghith, N, Ghozali, G, Ghozy, S, Gialluisi, A, Giampaoli, S, Gilani, SA, Gill, PS, Gnedovskaya, E, Golechha, M, Goulart, AC, Guo, Y, Gupta, R, Gupta, VB, Gupta, VK, Gyanwali, P, Hafezi-Nejad, N, Hamidi, S, Hanif, A, Hankey, GJ, Hargono, A, Hashi, A, Hassan, TS, Hassen, HY, Havmoeller, RJ, Hay, S, Hayat, K, Hegazy, M, Herteliu, C, Holla, R, Hostiuc, S, Househ, M, Huang, J, Humayun, A, Hwang, B-F, Iacoviello, L, Iavicoli, I, Ibitoye, SE, Ilesanmi, OS, Ilic, IM, Ilic, MD, Iqbal, U, Irvani, SSN, Islam, SMS, Ismail, NE, Iso, H, Isola, G, Iwagami, M, Jacob, L, Jain, V, Jang, S-I, Jayapal, SK, Jayaram, S, Jayawardena, R, Jeemon, P, Jha, RP, Johnson, WD, Jonas, JB, Joseph, N, Jozwiak, JJ, Jurisson, M, Kalani, R, Kalhor, R, Kalkonde, Y, Kamath, A, Kamiab, Z, Kanchan, T, Kandel, H, Karch, A, Katoto, PDMC, Kayode, GA, Keshavarz, P, Khader, YS, Khan, EA, Khan, IA, Khan, M, Khan, MAB, Khatib, MN, Khubchandani, J, Kim, GR, Kim, MS, Kim, YJ, Kisa, A, Kisa, S, Kivimaki, M, Kolte, D, Koolivand, A, Laxminarayana, SLK, Koyanagi, A, Krishan, K, Krishnamoorthy, V, Krishnamurthi, R, Kumar, GA, Kusuma, D, La Vecchia, C, Lacey, B, Lak, HM, Lallukka, T, Lasrado, S, Lavados, PM, Leonardi, M, Li, B, Li, S, Lin, H, Lin, R-T, Liu, X, Lo, WD, Lorkowski, S, Lucchetti, G, Saute, RL, Razek, HMAE, Magnani, FG, Mahajan, PB, Majeed, A, Makki, A, Malekzadeh, R, Malik, AA, Manafi, N, Mansournia, MA, Mantovani, LG, Martini, S, Mazzaglia, G, Mehndiratta, MM, Menezes, RG, Meretoja, A, Mersha, AG, Jonasson, JM, Miazgowski, B, Miazgowski, T, Michalek, IM, Mirrakhimov, EM, Mohammad, Y, Mohammadian-Hafshejani, A, Mohammed, S, Mokdad, AH, Mokhayeri, Y, Molokhia, M, Moni, MA, Al Montasir, A, Moradzadeh, R, Morawska, L, Morze, J, Muruet, W, Musa, KI, Nagarajan, AJ, Naghavi, M, Swamy, SN, Nascimento, BR, Negoi, RI, Kandel, SN, Trang, HN, Norrving, B, Noubiap, JJ, Nwatah, VE, Oancea, B, Odukoya, OO, Olagunju, AT, Orru, H, Owolabi, MO, Padubidri, JR, Pana, A, Parekh, T, Park, E-C, Kan, FP, Pathak, M, Peres, MFP, Perianayagam, A, Truong-Minh, P, Piradov, MA, Podder, V, Polinder, S, Postma, MJ, Pourshams, A, Radfar, A, Rafiei, A, Raggi, A, Rahim, F, Rahimi-Movaghar, V, Rahman, M, Rahman, MA, Rahmani, AM, Rajai, N, Ranasinghe, P, Rao, CR, Rao, SJ, Rathi, P, Rawaf, DL, Rawaf, S, Reitsma, MB, Renjith, V, Renzaho, AMN, Rezapour, A, Rodriguez, JAB, Roever, L, Romoli, M, Rynkiewicz, A, Sacco, S, Sadeghi, M, Moghaddam, SS, Sahebkar, A, Saif-Ur-Rahman, K, Salah, R, Samaei, M, Samy, AM, Santos, IS, Santric-Milicevic, MM, Sarrafzadegan, N, Sathian, B, Sattin, D, Schiavolin, S, Schlaich, MP, Schmidt, MI, Schutte, AE, Sepanlou, SG, Seylani, A, Sha, F, Shahabi, S, Shaikh, MA, Shannawaz, M, Shawon, MSR, Sheikh, A, Sheikhbahaei, S, Shibuya, K, Siabani, S, Silva, DAS, Singh, JA, Singh, JK, Skryabin, VY, Skryabina, AA, Sobaih, BH, Stortecky, S, Stranges, S, Tadesse, EG, Tarigan, IU, Temsah, M-H, Teuschl, Y, Thrift, AG, Tonelli, M, Tovani-Palone, MR, Bach, XT, Tripathi, M, Tsegaye, GW, Ullah, A, Unim, B, Unnikrishnan, B, Vakilian, A, Tahbaz, SV, Vasankari, TJ, Venketasubramanian, N, Vervoort, D, Vo, B, Volovici, V, Vosoughi, K, Giang, TV, Linh, GV, Wafa, HA, Waheed, Y, Wang, Y, Wijeratne, T, Winkler, AS, Wolfe, CDA, Woodward, M, Wu, JH, Hanson, SW, Xu, X, Yadav, L, Yadollahpour, A, Jabbari, SHY, Yamagishi, K, Yatsuya, H, Yonemoto, N, Yu, C, Yunusa, I, Zaman, MS, Bin Zaman, S, Zamanian, M, Zand, R, Zandifar, A, Zastrozhin, MS, Zastrozhina, A, Zhang, Y, Zhang, Z-J, Zhong, C, Zuniga, YMH, Murray, CJL, Feigin, VL, Stark, BA, Johnson, CO, Roth, GA, Bisignano, C, Abady, GG, Abbasifard, M, Abbasi-Kangevari, M, Abd-Allah, F, Abedi, V, Abualhasan, A, Abu-Rmeileh, NM, Abushouk, A, Adebayo, OM, Agarwal, G, Agasthi, P, Ahinkorah, BO, Ahmad, S, Ahmadi, S, Salih, YA, Aji, B, Akbarpour, S, Akinyemi, RO, Al Hamad, H, Alahdab, F, Alif, SM, Alipour, V, Aljunid, SM, Almustanyir, S, Al-Raddadi, RM, Salman, RA-S, Alvis-Guzman, N, Ancuceanu, R, Anderlini, D, Anderson, JA, Ansar, A, Antonazzo, IC, Arabloo, J, Arnlov, J, Artanti, KD, Aryan, Z, Asgari, S, Ashraf, T, Athar, M, Atreya, A, Ausloos, M, Baig, AA, Baltatu, OC, Banach, M, Barboza, MA, Barker-Collo, SL, Barnighausen, TW, Barone, MTU, Basu, S, Bazmandegan, G, Beghi, E, Beheshti, M, Bejot, Y, Bell, AW, Bennett, DA, Bensenor, IM, Bezabhe, WM, Bezabih, YM, Bhagavathula, AS, Bhardwaj, P, Bhattacharyya, K, Bijani, A, Bikbov, B, Birhanu, MM, Boloor, A, Bonny, A, Brauer, M, Brenner, H, Bryazka, D, Butt, ZA, dos Santos, FLC, Campos-Nonato, IR, Cantu-Brito, C, Carrero, JJ, Castaneda-Orjuela, CA, Catapano, AL, Chakraborty, PA, Charan, J, Choudhari, SG, Chowdhury, EK, Chu, D-T, Chung, S-C, Colozza, D, Costa, VM, Costanzo, S, Criqui, MH, Dadras, O, Dagnew, B, Dai, X, Dalal, K, Damasceno, AAM, D'Amico, E, Dandona, L, Dandona, R, Gela, JD, Davletov, K, De La Cruz-Gongora, V, Desai, R, Dhamnetiya, D, Dharmaratne, SD, Dhimal, ML, Dhimal, M, Diaz, D, Dichgans, M, Dokova, K, Doshi, R, Douiri, A, Duncan, BB, Eftekharzadeh, S, Ekholuenetale, M, El Nahas, N, Elgendy, IY, Elhadi, M, El-Jaafary, S, Endres, M, Endries, AY, Erku, DA, Faraon, EJA, Farooque, U, Farzadfar, F, Feroze, AH, Filip, I, Fischer, F, Flood, D, Gad, MM, Gaidhane, S, Gheshlagh, RG, Ghashghaee, A, Ghith, N, Ghozali, G, Ghozy, S, Gialluisi, A, Giampaoli, S, Gilani, SA, Gill, PS, Gnedovskaya, E, Golechha, M, Goulart, AC, Guo, Y, Gupta, R, Gupta, VB, Gupta, VK, Gyanwali, P, Hafezi-Nejad, N, Hamidi, S, Hanif, A, Hankey, GJ, Hargono, A, Hashi, A, Hassan, TS, Hassen, HY, Havmoeller, RJ, Hay, S, Hayat, K, Hegazy, M, Herteliu, C, Holla, R, Hostiuc, S, Househ, M, Huang, J, Humayun, A, Hwang, B-F, Iacoviello, L, Iavicoli, I, Ibitoye, SE, Ilesanmi, OS, Ilic, IM, Ilic, MD, Iqbal, U, Irvani, SSN, Islam, SMS, Ismail, NE, Iso, H, Isola, G, Iwagami, M, Jacob, L, Jain, V, Jang, S-I, Jayapal, SK, Jayaram, S, Jayawardena, R, Jeemon, P, Jha, RP, Johnson, WD, Jonas, JB, Joseph, N, Jozwiak, JJ, Jurisson, M, Kalani, R, Kalhor, R, Kalkonde, Y, Kamath, A, Kamiab, Z, Kanchan, T, Kandel, H, Karch, A, Katoto, PDMC, Kayode, GA, Keshavarz, P, Khader, YS, Khan, EA, Khan, IA, Khan, M, Khan, MAB, Khatib, MN, Khubchandani, J, Kim, GR, Kim, MS, Kim, YJ, Kisa, A, Kisa, S, Kivimaki, M, Kolte, D, Koolivand, A, Laxminarayana, SLK, Koyanagi, A, Krishan, K, Krishnamoorthy, V, Krishnamurthi, R, Kumar, GA, Kusuma, D, La Vecchia, C, Lacey, B, Lak, HM, Lallukka, T, Lasrado, S, Lavados, PM, Leonardi, M, Li, B, Li, S, Lin, H, Lin, R-T, Liu, X, Lo, WD, Lorkowski, S, Lucchetti, G, Saute, RL, Razek, HMAE, Magnani, FG, Mahajan, PB, Majeed, A, Makki, A, Malekzadeh, R, Malik, AA, Manafi, N, Mansournia, MA, Mantovani, LG, Martini, S, Mazzaglia, G, Mehndiratta, MM, Menezes, RG, Meretoja, A, Mersha, AG, Jonasson, JM, Miazgowski, B, Miazgowski, T, Michalek, IM, Mirrakhimov, EM, Mohammad, Y, Mohammadian-Hafshejani, A, Mohammed, S, Mokdad, AH, Mokhayeri, Y, Molokhia, M, Moni, MA, Al Montasir, A, Moradzadeh, R, Morawska, L, Morze, J, Muruet, W, Musa, KI, Nagarajan, AJ, Naghavi, M, Swamy, SN, Nascimento, BR, Negoi, RI, Kandel, SN, Trang, HN, Norrving, B, Noubiap, JJ, Nwatah, VE, Oancea, B, Odukoya, OO, Olagunju, AT, Orru, H, Owolabi, MO, Padubidri, JR, Pana, A, Parekh, T, Park, E-C, Kan, FP, Pathak, M, Peres, MFP, Perianayagam, A, Truong-Minh, P, Piradov, MA, Podder, V, Polinder, S, Postma, MJ, Pourshams, A, Radfar, A, Rafiei, A, Raggi, A, Rahim, F, Rahimi-Movaghar, V, Rahman, M, Rahman, MA, Rahmani, AM, Rajai, N, Ranasinghe, P, Rao, CR, Rao, SJ, Rathi, P, Rawaf, DL, Rawaf, S, Reitsma, MB, Renjith, V, Renzaho, AMN, Rezapour, A, Rodriguez, JAB, Roever, L, Romoli, M, Rynkiewicz, A, Sacco, S, Sadeghi, M, Moghaddam, SS, Sahebkar, A, Saif-Ur-Rahman, K, Salah, R, Samaei, M, Samy, AM, Santos, IS, Santric-Milicevic, MM, Sarrafzadegan, N, Sathian, B, Sattin, D, Schiavolin, S, Schlaich, MP, Schmidt, MI, Schutte, AE, Sepanlou, SG, Seylani, A, Sha, F, Shahabi, S, Shaikh, MA, Shannawaz, M, Shawon, MSR, Sheikh, A, Sheikhbahaei, S, Shibuya, K, Siabani, S, Silva, DAS, Singh, JA, Singh, JK, Skryabin, VY, Skryabina, AA, Sobaih, BH, Stortecky, S, Stranges, S, Tadesse, EG, Tarigan, IU, Temsah, M-H, Teuschl, Y, Thrift, AG, Tonelli, M, Tovani-Palone, MR, Bach, XT, Tripathi, M, Tsegaye, GW, Ullah, A, Unim, B, Unnikrishnan, B, Vakilian, A, Tahbaz, SV, Vasankari, TJ, Venketasubramanian, N, Vervoort, D, Vo, B, Volovici, V, Vosoughi, K, Giang, TV, Linh, GV, Wafa, HA, Waheed, Y, Wang, Y, Wijeratne, T, Winkler, AS, Wolfe, CDA, Woodward, M, Wu, JH, Hanson, SW, Xu, X, Yadav, L, Yadollahpour, A, Jabbari, SHY, Yamagishi, K, Yatsuya, H, Yonemoto, N, Yu, C, Yunusa, I, Zaman, MS, Bin Zaman, S, Zamanian, M, Zand, R, Zandifar, A, Zastrozhin, MS, Zastrozhina, A, Zhang, Y, Zhang, Z-J, Zhong, C, Zuniga, YMH, and Murray, CJL

Abstract

BACKGROUND: Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence, mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a standardised and comprehensive measurement of these metrics at global, regional, and national levels. METHODS: We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. These estimates were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes combined, and stratified by sex, age group, and World Bank country income level. FINDINGS: In 2019, there were 12·2 million (95% UI 11·0-13·6) incident cases of stroke, 101 million (93·2-111) prevalent cases of stroke, 143 million (133-153) DALYs due to stroke, and 6·55 million (6·00-7·02) deaths from stroke. Globally, stroke remained the second-leading cause of death (11·6% [10·8-12·2] of total deaths) and the third-leading cause of death and disability combined (5·7% [5·1-6·2] of total DALYs) in 2019. From 1990 to 2019, the absolute number of incident strokes increased by 70·0% (67·0-73·0), prevalent strokes increased by 85·0% (83·0-88·0), deaths from stroke increased by 43·0% (31·0-55·0), and DALYs due to stroke increased by 32·0% (22·0-42·0). During the same period, age-standardised rates of stroke incidence decreased by 17·0% (15·0-18·0), mortality decreased by 36·0% (31·0-42·0), prevalence decreased by 6·0% (5·0-7·0), and DALYs decreased by 36·0% (31·0-42·0). However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0-24·0) and incidence rat

Published
2021

7. Global impact of COVID-19 on stroke care

Author

Nogueira, RG, Abdalkader, M, Qureshi, MM, Frankel, MR, Mansour, OY, Yamagami, H, Qiu, Z, Farhoudi, M, Siegler, JE, Yaghi, S, Raz, E, Sakai, N, Ohara, N, Piotin, M, Mechtouff, L, Eker, O, Chalumeau, V, Kleinig, TJ, Pop, R, Liu, J, Winters, HS, Shang, X, Rodriguez Vasquez, A, Blasco, J, Arenillas, JF, Martinez-Galdamez, M, Brehm, A, Psychogios, M-N, Lylyk, P, Haussen, DC, Al-Bayati, AR, Mohammaden, MH, Fonseca, L, Luis Silva, M, Montalverne, F, Renieri, L, Mangiafico, S, Fischer, U, Gralla, J, Frei, D, Chugh, C, Mehta, BP, Nagel, S, Mohlenbruch, M, Ortega-Gutierrez, S, Farooqui, M, Hassan, AE, Taylor, A, Lapergue, B, Consoli, A, Campbell, BCV, Sharma, M, Walker, M, Van Horn, N, Fiehler, J, Huy, TN, Nguyen, QT, Watanabe, D, Zhang, H, Le, HV, Nguyen, VQ, Shah, R, Devlin, T, Khandelwal, P, Linfante, I, Izzath, W, Lavados, PM, Olavarria, VV, Silva, GS, de Carvalho Sousa, AV, Kirmani, J, Bendszus, M, Amano, T, Yamamoto, R, Doijiri, R, Tokuda, N, Yamada, T, Terasaki, T, Yazawa, Y, Morris, JG, Griffin, E, Thornton, J, Lavoie, P, Matouk, C, Hill, MD, Demchuk, AM, Killer-Oberpfalzer, M, Nahab, F, Altschul, D, Ramos-Pachon, A, Perez de la Ossa, N, Kikano, R, Boisseau, W, Walker, G, Cordina, SM, Puri, A, Kuhn, AL, Gandhi, D, Ramakrishnan, P, Novakovic-White, R, Chebl, A, Kargiotis, O, Czap, A, Zha, A, Masoud, HE, Lopez, C, Ozretic, D, Al-Mufti, F, Zie, W, Duan, Z, Yuan, Z, Huang, W, Hao, Y, Luo, J, Kalousek, V, Bourcier, R, Guile, R, Hetts, S, Al-Jehani, HM, AlHazzani, A, Sadeghi-Hokmabadi, E, Teleb, M, Payne, J, Lee, JS, Hong, JM, Sohn, S-I, Hwang, Y-H, Shin, DH, Roh, HG, Edgell, R, Khatri, R, Smith, A, Malik, A, Liebeskind, D, Herial, N, Jabbour, P, Magalhaes, P, Ozdemir, AO, Aykac, O, Uwatoko, T, Dembo, T, Shimizu, H, Sugiura, Y, Miyashita, F, Fukuda, H, Miyake, K, Shimbo, J, Sugimura, Y, Beer-Furlan, A, Joshi, K, Catanese, L, Abud, DG, Pontes Neto, O, Mehrpour, M, Al Hashmi, A, Saqqur, M, Mostafa, A, Fifi, JT, Hussain, S, John, S, Gupta, R, Sivan-Hoffmann, R, Reznik, A, Sani, AF, Geyik, S, Akil, ECR, Churojana, A, Ghoreishi, A, Saadatnia, M, Sharifipour, E, Ma, A, Faulder, K, Wu, T, Leung, L, Malek, A, Voetsch, B, Wakhloo, A, Rivera, R, Barrientos Iman, DM, Pikula, A, Lioutas, V-A, Thomalla, G, Birnbaum, L, Machi, P, Bernava, G, McDermott, M, Kleindorfer, D, Wong, K, Patterson, MS, Fiorot, JA, Huded, V, Mack, W, Tenser, M, Eskey, C, Multani, S, Kelly, M, Janardhan, V, Cornett, O, Singh, V, Murayama, Y, Mokin, M, Yang, P, Zhang, X, Yin, C, Han, H, Peng, Y, Chen, W, Crosa, R, Frudit, ME, Pandian, JD, Kulkarni, A, Yagita, Y, Takenobu, Y, Matsumaru, Y, Yamada, S, Kono, R, Kanamaru, T, Yamazaki, H, Sakaguchi, M, Todo, K, Yamamoto, N, Sonoda, K, Yoshida, T, Hashimoto, H, Nakahara, I, Cora, E, Volders, D, Ducroux, C, Shoamanesh, A, Ospel, J, Kaliaev, A, Ahmed, S, Rashid, U, Rebello, LC, Pereira, VM, Fahed, R, Chen, M, Sheth, SA, Palaiodimou, L, Tsivgoulis, G, Chandra, R, Koyfman, F, Leung, T, Khosravani, H, Dharmadhikari, S, Frisullo, G, Calabresi, P, Tsiskaridze, A, Lobjanidze, N, Grigoryan, M, Czlonkowska, A, de Sousa, DA, Demeestere, J, Liang, C, Sangha, N, Lutsep, HL, Ayo-Martin, O, Cruz-Culebras, A, Tran, AD, Young, CY, Cordonnier, C, Caparros, F, Alonso De Lecinana, M, Fuentes, B, Yavagal, D, Jovin, T, Spelle, L, Moret, J, Khatri, P, Zaidat, O, Raymond, J, Martins, S, Thanh, N, Nogueira, RG, Abdalkader, M, Qureshi, MM, Frankel, MR, Mansour, OY, Yamagami, H, Qiu, Z, Farhoudi, M, Siegler, JE, Yaghi, S, Raz, E, Sakai, N, Ohara, N, Piotin, M, Mechtouff, L, Eker, O, Chalumeau, V, Kleinig, TJ, Pop, R, Liu, J, Winters, HS, Shang, X, Rodriguez Vasquez, A, Blasco, J, Arenillas, JF, Martinez-Galdamez, M, Brehm, A, Psychogios, M-N, Lylyk, P, Haussen, DC, Al-Bayati, AR, Mohammaden, MH, Fonseca, L, Luis Silva, M, Montalverne, F, Renieri, L, Mangiafico, S, Fischer, U, Gralla, J, Frei, D, Chugh, C, Mehta, BP, Nagel, S, Mohlenbruch, M, Ortega-Gutierrez, S, Farooqui, M, Hassan, AE, Taylor, A, Lapergue, B, Consoli, A, Campbell, BCV, Sharma, M, Walker, M, Van Horn, N, Fiehler, J, Huy, TN, Nguyen, QT, Watanabe, D, Zhang, H, Le, HV, Nguyen, VQ, Shah, R, Devlin, T, Khandelwal, P, Linfante, I, Izzath, W, Lavados, PM, Olavarria, VV, Silva, GS, de Carvalho Sousa, AV, Kirmani, J, Bendszus, M, Amano, T, Yamamoto, R, Doijiri, R, Tokuda, N, Yamada, T, Terasaki, T, Yazawa, Y, Morris, JG, Griffin, E, Thornton, J, Lavoie, P, Matouk, C, Hill, MD, Demchuk, AM, Killer-Oberpfalzer, M, Nahab, F, Altschul, D, Ramos-Pachon, A, Perez de la Ossa, N, Kikano, R, Boisseau, W, Walker, G, Cordina, SM, Puri, A, Kuhn, AL, Gandhi, D, Ramakrishnan, P, Novakovic-White, R, Chebl, A, Kargiotis, O, Czap, A, Zha, A, Masoud, HE, Lopez, C, Ozretic, D, Al-Mufti, F, Zie, W, Duan, Z, Yuan, Z, Huang, W, Hao, Y, Luo, J, Kalousek, V, Bourcier, R, Guile, R, Hetts, S, Al-Jehani, HM, AlHazzani, A, Sadeghi-Hokmabadi, E, Teleb, M, Payne, J, Lee, JS, Hong, JM, Sohn, S-I, Hwang, Y-H, Shin, DH, Roh, HG, Edgell, R, Khatri, R, Smith, A, Malik, A, Liebeskind, D, Herial, N, Jabbour, P, Magalhaes, P, Ozdemir, AO, Aykac, O, Uwatoko, T, Dembo, T, Shimizu, H, Sugiura, Y, Miyashita, F, Fukuda, H, Miyake, K, Shimbo, J, Sugimura, Y, Beer-Furlan, A, Joshi, K, Catanese, L, Abud, DG, Pontes Neto, O, Mehrpour, M, Al Hashmi, A, Saqqur, M, Mostafa, A, Fifi, JT, Hussain, S, John, S, Gupta, R, Sivan-Hoffmann, R, Reznik, A, Sani, AF, Geyik, S, Akil, ECR, Churojana, A, Ghoreishi, A, Saadatnia, M, Sharifipour, E, Ma, A, Faulder, K, Wu, T, Leung, L, Malek, A, Voetsch, B, Wakhloo, A, Rivera, R, Barrientos Iman, DM, Pikula, A, Lioutas, V-A, Thomalla, G, Birnbaum, L, Machi, P, Bernava, G, McDermott, M, Kleindorfer, D, Wong, K, Patterson, MS, Fiorot, JA, Huded, V, Mack, W, Tenser, M, Eskey, C, Multani, S, Kelly, M, Janardhan, V, Cornett, O, Singh, V, Murayama, Y, Mokin, M, Yang, P, Zhang, X, Yin, C, Han, H, Peng, Y, Chen, W, Crosa, R, Frudit, ME, Pandian, JD, Kulkarni, A, Yagita, Y, Takenobu, Y, Matsumaru, Y, Yamada, S, Kono, R, Kanamaru, T, Yamazaki, H, Sakaguchi, M, Todo, K, Yamamoto, N, Sonoda, K, Yoshida, T, Hashimoto, H, Nakahara, I, Cora, E, Volders, D, Ducroux, C, Shoamanesh, A, Ospel, J, Kaliaev, A, Ahmed, S, Rashid, U, Rebello, LC, Pereira, VM, Fahed, R, Chen, M, Sheth, SA, Palaiodimou, L, Tsivgoulis, G, Chandra, R, Koyfman, F, Leung, T, Khosravani, H, Dharmadhikari, S, Frisullo, G, Calabresi, P, Tsiskaridze, A, Lobjanidze, N, Grigoryan, M, Czlonkowska, A, de Sousa, DA, Demeestere, J, Liang, C, Sangha, N, Lutsep, HL, Ayo-Martin, O, Cruz-Culebras, A, Tran, AD, Young, CY, Cordonnier, C, Caparros, F, Alonso De Lecinana, M, Fuentes, B, Yavagal, D, Jovin, T, Spelle, L, Moret, J, Khatri, P, Zaidat, O, Raymond, J, Martins, S, and Thanh, N

Abstract

BACKGROUND: The COVID-19 pandemic led to profound changes in the organization of health care systems worldwide. AIMS: We sought to measure the global impact of the COVID-19 pandemic on the volumes for mechanical thrombectomy, stroke, and intracranial hemorrhage hospitalizations over a three-month period at the height of the pandemic (1 March-31 May 2020) compared with two control three-month periods (immediately preceding and one year prior). METHODS: Retrospective, observational, international study, across 6 continents, 40 countries, and 187 comprehensive stroke centers. The diagnoses were identified by their ICD-10 codes and/or classifications in stroke databases at participating centers. RESULTS: The hospitalization volumes for any stroke, intracranial hemorrhage, and mechanical thrombectomy were 26,699, 4002, and 5191 in the three months immediately before versus 21,576, 3540, and 4533 during the first three pandemic months, representing declines of 19.2% (95%CI, -19.7 to -18.7), 11.5% (95%CI, -12.6 to -10.6), and 12.7% (95%CI, -13.6 to -11.8), respectively. The decreases were noted across centers with high, mid, and low COVID-19 hospitalization burden, and also across high, mid, and low volume stroke/mechanical thrombectomy centers. High-volume COVID-19 centers (-20.5%) had greater declines in mechanical thrombectomy volumes than mid- (-10.1%) and low-volume (-8.7%) centers (p < 0.0001). There was a 1.5% stroke rate across 54,366 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.9% (784/20,250) of all stroke admissions. CONCLUSION: The COVID-19 pandemic was associated with a global decline in the volume of overall stroke hospitalizations, mechanical thrombectomy procedures, and intracranial hemorrhage admission volumes. Despite geographic variations, these volume reductions were observed regardless of COVID-19 hospitalization burden and pre-pandemic stroke/mechanical thrombectomy volumes.

Published
2021

8. Dysphagia screening and risks of pneumonia and adverse outcomes after acute stroke: An international multicenter study

Author

Ouyang M, Boaden E, Arima H, Lavados PM, Billot L, Hackett ML, Olavarría VV, Muñoz-Venturelli P, Song L, Rogers K, Middleton S, Pontes-Neto OM, Lee T-H, Watkins C, Robinson T, Anderson CS, and HeadPoST Investigators

Subjects
Neurology & Neurosurgery, 1103 Clinical Sciences, 1109 Neurosciences
Abstract

BACKGROUND:Dysphagia is associated with aspiration pneumonia after stroke. Data are limited on the influences of dysphagia screen and assessment in clinical practice. AIMS:To determine associations between a "brief" screen and "detailed" assessment of dysphagia on clinical outcomes in acute stroke patients. METHODS:A prospective cohort study analyzed retrospectively using data from a multicenter, cluster cross-over, randomized controlled trial (Head Positioning in Acute Stroke Trial [HeadPoST]) from 114 hospitals in nine countries. HeadPoST included 11,093 acute stroke patients randomized to lying-flat or sitting-up head positioning. Herein, we report predefined secondary analyses of the association of dysphagia screening and assessment and clinical outcomes of pneumonia and death or disability (modified Rankin scale 3-6) at 90 days. RESULTS:Overall, 8784 (79.2%) and 3917 (35.3%) patients were screened and assessed for dysphagia, respectively, but the frequency and timing for each varied widely across regions. Neither use of a screen nor an assessment for dysphagia was associated with the outcomes, but their results were compared to "screen-pass" patients, those who failed had higher risks of pneumonia (adjusted odds ratio [aOR] = 3.00, 95% confidence interval [CI] = 2.18-4.10) and death or disability (aOR = 1.66, 95% CI = 1.41-1.95). Similar results were evidence for the results of an assessment for dysphagia. Subsequent feeding restrictions were related to higher risk of pneumonia in patients failed dysphagia screen or assessment (aOR = 4.06, 95% CI = 1.72-9.54). CONCLUSIONS:Failing a dysphagia screen is associated with increased risks of pneumonia and poor clinical outcome after acute stroke. Further studies concentrate on determining the effective subsequent feeding actions are needed to improve patient outcomes.

Published
2020

9. Quantifying regional variations in components of acute stroke unit (ASU) care in the international HeadPoST study

Author

Ouyang, M, Zhang, Y, Wang, X, Song, L, Billot, L, Robinson, T, Lavados, PM, Arima, H, Hackett, ML, Olavarría, VV, Muñoz-Venturelli, P, Middleton, S, Watkins, CL, Pontes-Neto, OM, Lee, TH, Brunser, AM, Anderson, CS, Ouyang, M, Zhang, Y, Wang, X, Song, L, Billot, L, Robinson, T, Lavados, PM, Arima, H, Hackett, ML, Olavarría, VV, Muñoz-Venturelli, P, Middleton, S, Watkins, CL, Pontes-Neto, OM, Lee, TH, Brunser, AM, and Anderson, CS

Abstract

Objective: Access to acute stroke unit (ASU) care is known to vary worldwide. We aimed to quantify regional variations in the various components of ASU care. Method: Secondary analysis of the Head Positioning in acute Stroke Trial (HeadPoST), an international, multicentre, cluster crossover trial of head-up versus head-down positioning in 11,093 acute stroke patients at 114 hospitals in 9 countries. Patients characteristics and 11 standard components of processes of care were described according to ASU admission within and across four economically-defined regional groups (Australia/UK, China [includes Taiwan], India/Sri Lanka, and South America [Brazil/Chile/Colombia]). Variations in process of ASU care estimates were obtained in hierarchical mixed models, with adjustment for study design and potential patient- and hospital-level confounders. Results: Of 11,086 patients included in analyses, 59.7% (n = 6620) had an ASU admission. In China, India/Sri Lanka and South America, ASU patients were older, had greater neurological severity and more premorbid conditions than non-ASU patients. ASU patients were more likely to receive reperfusion therapy and multidisciplinary care within regions, but the components of care varied across regions. With Australia/UK as reference, patients in other regions had a lower probability of receiving reperfusion therapy, especially in India/Sri Lanka (adjusted odds ratio [aOR] 0.27, 95% confidence interval [CI] 0.12–0.63) and multidisciplinary care (mainly in formal dysphagia assessment, physiotherapy and occupational therapy). Conclusion: There is significant variation in the components of stroke care across economically-defined regions of the world. Ongoing efforts are required to reduce disparities and optimise health outcomes, especially in resource poor areas. Clinical trial registration: HeadPoST is registered at ClinicalTrials.gov (NCT02162017).

Published
2020

10. Ethnicity and Other Determinants of Quality of Functional Outcome in Acute Ischemic Stroke: The ENCHANTED Trial

Author

Chen, X, Wang, X, Delcourt, C, Li, J, Arima, H, Hackett, ML, Robinson, T, Lavados, PM, Lindley, RI, Chalmers, J, Anderson, CS, Chen, X, Wang, X, Delcourt, C, Li, J, Arima, H, Hackett, ML, Robinson, T, Lavados, PM, Lindley, RI, Chalmers, J, and Anderson, CS

Abstract

Background and Purpose-Patient-centered outcomes are important. We aimed to determine predictors of health-related quality of life (HRQoL) and develop utility-weighted modified Rankin Scale (mRS) scores in thrombolyzed acute ischemic stroke patients from both arms of ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study). Methods-ENCHANTED was an international quasi-factorial clinical trial of different doses of intravenous alteplase and intensities of blood pressure control in acute ischemic stroke patients, with outcomes on the 5-Dimensional European Quality of Life Scale and mRS assessed at 90 days post-randomization. Logistic regression models were used to identify baseline predictors of poor HRQoL (≤mean 5-Dimensional European Quality of Life Scale utility scores). Ordinary least squares regression derived utility-weighted mRS scores. Results-In 4016 acute ischemic stroke patients with complete 5-Dimensional European Quality of Life Scale and mRS data, independent predictors of poor HRQoL were older age (odds ratio, 1.19 [95% CI, 1.12-1.27], per 10-year increase), non-Asian ethnicity (1.91 [1.61-2.27]), greater stroke severity on the National Institutes of Health Stroke Scale (1.11 [1.09-1.12]), diabetes mellitus (1.41 [1.18-1.69]), premorbid disability (mRS score 1 versus 0; 1.62 [1.33-1.97]), large vessel atheromatous pathogenesis (1.32 [1.12-1.54]), and proxy respondent (2.35 [2.01-2.74]). Sensitivity analyses indicate the ethnicity influence on HRQoL was driven by the high proportion of Chinese (62.9% of Asian) participants with better HRQoL compared with non-Chinese or other Asian groups. Derived utility values across mRS scores 0 to 5 were 0.977, 0.885, 0.748, 0.576, 0.194, and-0.174, respectively. Correlations between mRS and 5-Dimensional European Quality of Life Scale scores were stronger in Asians. Conclusions-HRQoL is worse after thrombolyzed acute ischemic stroke in the elderly, non-Asians, with greater initial severity, diabetes

Published
2020

11. Impact of evidence-based stroke care on patient outcomes: A multilevel analysis of an international study

Author

Venturelli, PM, Li, X, Middleton, S, Watkins, C, Lavados, PM, Olavarría, VV, Brunser, A, Pontes-Neto, O, Santos, TEG, Arima, H, Billot, L, Hackett, ML, Song, L, Robinson, T, Anderson, CS, Venturelli, PM, Li, X, Middleton, S, Watkins, C, Lavados, PM, Olavarría, VV, Brunser, A, Pontes-Neto, O, Santos, TEG, Arima, H, Billot, L, Hackett, ML, Song, L, Robinson, T, and Anderson, CS

Abstract

Background The uptake of proven stroke treatments varies widely. We aimed to determine the association of evidence-based processes of care for acute ischemic stroke (AIS) and clinical outcome of patients who participated in the HEADPOST (Head Positioning in Acute Stroke Trial), a multicenter cluster crossover trial of lying flat versus sitting up, head positioning in acute stroke. Methods and Results Use of 8 AIS processes of care were considered: Reperfusion therapy in eligible patients; acute stroke unit care; antihypertensive, antiplatelet, statin, and anticoagulation for atrial fibrillation; dysphagia assessment; and physiotherapist review. Hierarchical, mixed, logistic regression models were performed to determine associations with good outcome (modified Rankin Scale scores 0-2) at 90 days, adjusted for patient and hospital variables. Among 9485 patients with AIS, implementation of all processes of care in eligible patients, or “defect-free” care, was associated with improved outcome (odds ratio, 1.40; 95% CI, 1.18-1.65) and better survival (odds ratio, 2.23; 95% CI, 1.62-3.09). Defect-free stroke care was also significantly associated with excellent outcome (modified Rankin Scale score 0-1) (odds ratio, 1.22; 95% CI, 1.04-1.43). No hospital characteristic was independently predictive of outcome. Only 1445 (15%) of eligible patients with AIS received all processes of care, with significant regional variations in overall and individual rates. Conclusions Use of evidence-based care is associated with improved clinical outcome in AIS. Strategies are required to address regional variation in the use of proven AIS treatments.

Published
2019

12. Blood pressure variability and outcome in acute ischemic and hemorrhagic stroke: a post hoc analysis of the HeadPoST study

Author

Minhas, JS, Wang, X, Lavados, PM, Moullaali, TJ, Arima, H, Billot, L, Hackett, ML, Olavarria, VV, Middleton, S, Pontes-Neto, O, De Silva, HA, Lee, TH, Pandian, JD, Mead, GE, Watkins, C, Chalmers, J, Anderson, CS, Robinson, TG, Minhas, JS, Wang, X, Lavados, PM, Moullaali, TJ, Arima, H, Billot, L, Hackett, ML, Olavarria, VV, Middleton, S, Pontes-Neto, O, De Silva, HA, Lee, TH, Pandian, JD, Mead, GE, Watkins, C, Chalmers, J, Anderson, CS, and Robinson, TG

Abstract

The Head Positioning in Acute Stroke Trial (HeadPoST) is a pragmatic, international, cluster crossover randomized trial of 11,093 patients with acute stroke assigned to a lying-flat (0°) or sitting-up (head elevated ≥30°) position. This post hoc analysis aimed to determine the association between blood pressure variability (BPV) and outcomes for patients from a wide range of international clinical settings and how the association was modified by randomized head position. BPV was defined according to the standard criteria, with the key parameter considered the coefficient of variation (CV) of systolic BP (SBP) over 24 h. Outcome was ordinal 90-day Modified Rankin Scale (mRS) score. The association was analyzed by ordinal, logistic regression, hierarchical, mixed models with fixed intervention (lying flat vs. sitting up), and fixed period, random cluster, and random cluster-period, effects. Nine thousand one hundred and fifty six (8324 acute ischemic stroke and 817 intracerebral hemorrhage; mean age 68.1 years; 39.2% women) were included in the analysis. CV of SBP had a significant linear association with unfavorable shift of mRS at 90 days (adjusted odds ratio 1.06, 95% confidence interval 1.02–1.11; P = 0.01). There was no heterogeneity of the association by randomized head positioning. In addition, CV of diastolic BP (DBP) (1.08, 1.03–1.12; P = 0.001) over 24 h post stroke was significantly associated with 3-month poor outcome. The association was more apparent in sitting-up position (1.12, 1.06–1.19) compared with lying-flat position (1.03, 0.98–1.09) (P interaction = 0.005). BPV was associated with adverse stroke outcome, and the magnitude of the association was greater with sitting-up head positioning in terms of DBP variability.

Published
2019

13. Applicability of ENCHANTED trial results to current acute ischemic stroke patients eligible for intravenous thrombolysis in England and Wales: Comparison with the Sentinel Stroke National Audit Programme registry

Author

Robinson, TG, Bray, BD, Paley, L, Sprigg, N, Wang, X, Arima, H, Bath, PM, Broderick, JP, Durham, AC, Kim, JS, Lavados, PM, Lee, TH, Martins, S, Nguyen, TH, Pandian, JD, Parsons, MW, Pontes-Neto, OM, Ricci, S, Sharma, VK, Wang, J, Woodward, M, Rudd, AG, Chalmers, J, S Anderson, C, Robinson, TG, Bray, BD, Paley, L, Sprigg, N, Wang, X, Arima, H, Bath, PM, Broderick, JP, Durham, AC, Kim, JS, Lavados, PM, Lee, TH, Martins, S, Nguyen, TH, Pandian, JD, Parsons, MW, Pontes-Neto, OM, Ricci, S, Sharma, VK, Wang, J, Woodward, M, Rudd, AG, Chalmers, J, and S Anderson, C

Abstract

Background: Randomized controlled trials provide high-level evidence, but the necessity to include selected patients may limit the generalisability of their results. Methods: Comparisons were made of baseline and outcome data between patients with acute ischemic stroke (AIS) recruited into the alteplase-dose arm of the international, multi-center, Enhanced Control of Hypertension and Thrombolysis Stroke study (ENCHANTED) in the United Kingdom (UK), and alteplase-treated AIS patients registered in the UK Sentinel Stroke National Audit Programme (SSNAP) registry, over the study period June 2012 to October 2015. Results: There were 770 AIS patients (41.2% female; mean age 72 years) included in ENCHANTED at sites in England and Wales, which was 19.5% of alteplase-treated AIS patients registered in the SSNAP registry. Trial participants were significantly older, had lower baseline neurological severity, less likely Asian, and had more premorbid symptoms, hypertension and atrial fibrillation. Although ENCHANTED participants had higher rates of symptomatic intracerebral hemorrhage than those in SSNAP, there were no differences in onset-to-treatment time, levels of disability (assessed by the modified Rankin scale) at hospital discharge, and mortality over 90 days between groups. Conclusions: Despite the high level of participation, equipoise over the dose of alteplase among UK clinician investigators favored the inclusion of older, frailer, milder AIS patients in the ENCHANTED trial. Clinical trial registration: Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01422616.

Published
2019

14. Lipid-lowering pretreatment and outcome following intravenous thrombolysis for acute ischaemic stroke: a post hoc analysis of the enhanced control of hypertension and thrombolysis stroke study trial

Author

Minhas, JS, Wang, X, Arima, H, Bath, PM, Billot, L, Broderick, JP, Donnan, GA, Kim, JS, Lavados, PM, Lee, TH, Martins, SCO, Olavarría, VV, Pandian, JD, Pontes-Neto, OM, Ricci, S, Sato, S, Sharma, VK, Thang, NH, Wang, JG, Woodward, M, Chalmers, J, Anderson, CS, Robinson, TG, Minhas, JS, Wang, X, Arima, H, Bath, PM, Billot, L, Broderick, JP, Donnan, GA, Kim, JS, Lavados, PM, Lee, TH, Martins, SCO, Olavarría, VV, Pandian, JD, Pontes-Neto, OM, Ricci, S, Sato, S, Sharma, VK, Thang, NH, Wang, JG, Woodward, M, Chalmers, J, Anderson, CS, and Robinson, TG

Abstract

Background: Debate exists as to whether statin pretreatment confers an increased risk of 90-day mortality and symptomatic intracranial haemorrhage (sICH) in acute ischaemic stroke (AIS) patients treated with intravenous thrombolysis. We assessed the effects of undifferentiated lipid-lowering pretreatment on outcomes and interaction with low-dose versus standard-dose alteplase in a post hoc subgroup -analysis of the Enhanced Control of Hypertension and Thrombolysis Stroke Study. Methods: In all, 3,284 thrombolysis-eligible AIS patients (mean age 66.6 years; 38% women), with information on lipid-lowering pretreatment, were randomly assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) intravenous alteplase within 4.5 h of symptom onset. Of the total number of patients, 615 (19%) received statin or other lipid-lowering pretreatment. The primary clinical outcome was combined endpoint of death or disability (modified Rankin Scale scores 2-6) at 90 days. Results: Compared with patients with no lipid-lowering pretreatment, those with lipid-lowering pretreatment were significantly older, more likely to be non-Asian and more likely to have a medical history including vascular co-morbidity. After propensity analysis assessment and adjustment for important baseline variables at the time of randomisation, as well as imbalances in management during the first 7 days of hospital admission, there were no significant differences in mortality (OR 0.85; 95% CI 0.58-1.25, p = 0.42), or in overall -90-day death and disability (OR 0.85, 95% CI 0.67-1.09, p = 0.19), despite a significant decrease in sICH among those with -lipid-lowering pretreatment according to the European Co-operative Acute Stroke Study 2 definition (OR 0.49, 95% CI 0.28-0.83, p = 0.009). No differences in key efficacy or safety outcomes were seen in patients with and without lipid-lowering pretreatment between low- and standard-dose alteplase arms. Conclusions: Lipid-lowering pretreatment is not associated wit

Published
2018

15. Global, regional, and national burden of neurological disorders during 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

Author

Feigin, VL, Abajobir, AA, Abate, KH, Abd-Allah, F, Abdulle, AM, Abera, SF, Abyu, GY, Ahmed, MB, Aichour, AN, Aichour, I, Aichour, MTE, Akinyemi, RO, Alabed, S, Al-Raddadi, R, Alvis-Guzman, N, Amare, AT, Ansari, H, Anwari, P, Arnlov, J, Asayesh, H, Asgedom, SW, Atey, TM, Avila-Burgos, L, Avokpaho, EFGA, Azarpazhooh, MR, Barac, A, Barboza, M, Barker-Collo, SL, Baernighausen, T, Bedi, N, Beghi, E, Bennett, DA, Bensenor, IM, Berhane, A, Betsu, BD, Bhaumik, S, Birlik, SM, Biryukov, S, Boneya, DJ, Bulto, LN, Carabin, H, Casey, D, Castaneda-Orjuela, CA, Catala-Lopez, F, Chen, H, Chitheer, AA, Chowdhury, R, Christensen, H, Dandona, L, Dandona, R, deVeber, GA, Dharmaratne, SD, Do, HP, Dokova, K, Dorsey, ER, Ellenbogen, RG, Eskandarieh, S, Farvid, MS, Fereshtehnejad, S-M, Fischer, F, Foreman, KJ, Geleijnse, JM, Gillum, RF, Giussani, G, Goldberg, EM, Gona, PN, Goulart, AC, Gugnani, HC, Gupta, R, Hachinski, V, Hamadeh, RR, Hambisa, M, Hankey, GJ, Hareri, HA, Havmoeller, R, Hay, SI, Heydarpour, P, Hotez, PJ, Jakovljevic, MMB, Javanbakht, M, Jeemon, P, Jonas, JB, Kalkonde, Y, Kandel, A, Karch, A, Kasaeian, A, Kastor, A, Keiyoro, PN, Khader, YS, Khalil, IA, Khan, EA, Khang, Y-H, Khoja, AT, Khubchandani, J, Kulkarni, C, Kim, D, Kim, YJ, Kivimaki, M, Kokubo, Y, Kosen, S, Kravchenko, M, Krishnamurthi, RV, Defo, BK, Kumar, GA, Kumar, R, Kyu, HH, Larsson, A, Lavados, PM, Li, Y, Liang, X, Liben, ML, Lo, WD, Logroscino, G, Lotufo, PA, Loy, CT, Mackay, MT, Abd El Razek, HM, Abd El Razek, MM, Majeed, A, Malekzadeh, R, Manhertz, T, Mantovani, LG, Massano, J, Mazidi, M, McAlinden, C, Mehata, S, Mehndiratta, MM, Memish, ZA, Mendoza, W, Mengistie, MA, Mensah, GA, Meretoja, A, Mezgebe, HB, Miller, TR, Mishra, SR, Ibrahim, NM, Mohammadi, A, Mohammed, KE, Mohammed, S, Mokdad, AH, Moradi-Lakeh, M, Velasquez, IM, Musa, KI, Naghavi, M, Ngunjiri, JW, Nguyen, CT, Nguyen, G, Nguyen, QL, Nguyen, TH, Nichols, E, Ningrum, DN, Nong, VM, Norrving, B, Noubiap, JJN, Ogbo, FA, Owolabi, MO, Pandian, JD, Parmar, PG, Pereira, DM, Petzold, M, Phillips, MR, Piradov, MA, Poulton, RG, Pourmalek, F, Qorbani, M, Rafay, A, Rahman, M, Rahman, MH, Rai, RK, Rajsic, S, Ranta, A, Rawaf, S, Renzaho, AMN, Rezai, MS, Roth, GA, Roshandel, G, Rubagotti, E, Sachdev, P, Safiri, S, Sahathevan, R, Sahraian, MA, Samy, AM, Santalucia, P, Santos, IS, Sartorius, B, Satpathy, M, Sawhney, M, Saylan, MI, Sepanlou, SG, Shaikh, MA, Shakir, R, Shamsizadeh, M, Sheth, KN, Shigematsu, M, Shoman, H, Silva, DA, Smith, M, Sobngwi, E, Sposato, LA, Stanaway, JD, Stein, DJ, Steiner, TJ, Stovner, LJ, Abdulkader, RS, Szoeke, CEI, Tabares-Seisdedos, R, Tanne, D, Theadom, AM, Thrift, AG, Tirschwell, DL, Topor-Madry, R, Tran, BX, Truelsen, T, Tuem, KB, Ukwaja, KN, Uthman, OA, Varakin, YY, Vasankari, T, Venketasubramanian, N, Vlassov, VV, Wadilo, F, Wakayo, T, Wallin, MT, Weiderpass, E, Westerman, R, Wijeratne, T, Wiysonge, CS, Woldu, MA, Wolfe, CDA, Xavier, D, Xu, G, Yano, Y, Yimam, HH, Yonemoto, N, Yu, C, Zaidi, Z, Zaki, MES, Zunt, JR, Murray, CJL, Vos, T, Disorders, GBDN, Feigin, V, Abajobir, A, Abate, K, Abd-Allah, F, Abdulle, A, Abera, S, Abyu, G, Ahmed, M, Aichour, A, Aichour, I, Aichour, M, Akinyemi, R, Alabed, S, Al-Raddadi, R, Alvis-Guzman, N, Amare, A, Ansari, H, Anwari, P, Ärnlöv, J, Asayesh, H, Asgedom, S, Atey, T, Avila-Burgos, L, Frinel, E, Avokpaho, G, Barac, A, Barboza, M, Barker-Collo, S, Bärnighausen, T, Bedi, N, Beghi, E, Bennett, D, Bensenor, I, Berhane, A, Betsu, B, Bhaumik, S, Birlik, S, Biryukov, S, Boneya, D, Bulto, L, Carabin, H, Casey, D, Castañeda-Orjuela, C, Catalá-López, F, Chen, H, Chitheer, A, Chowdhury, R, Christensen, H, Dandona, L, Dandona, R, Veber, G, Dharmaratne, S, Do, H, Dokova, K, Dorsey, E, Ellenbogen, R, Eskandarieh, S, Farvid, M, Fereshtehnejad, S, Fischer, F, Foreman, K, Geleijnse, J, Gillum, R, Giussani, G, Gona, P, Goulart, A, Gugnani, H, Gupta, R, Hamadeh, R, Hambisa, M, Hankey, G, Hareri, H, Havmoeller, R, Hay, S, Heydarpour, P, Hotez, P, Jakovljevic, M, Javanbakht, M, Jeemon, P, Jonas, J, Kalkonde, Y, Kandel, A, Karch, A, Kasaeian, A, Kastor, A, Keiyoro, P, Khader, Y, Khalil, I, Khan, E, Khang, Y, Tawfih, A, Khoja, A, Khubchandani, J, Kim, D, Kim, Y, Kivimaki, M, Kokubo, Y, Kosen, S, Kravchenko, M, Krishnamurthi, R, Defo, B, Kumar, G, Kumar, R, Kyu, H, Larsson, A, Lavados, P, Li, Y, Liang, X, Liben, M, Lo, W, Logroscino, G, Lotufo, P, Loy, C, Mackay, M, El Razek, H, El Razek, M, Majeed, A, Malekzadeh, R, Manhertz, T, Mantovani, L, Massano, J, Mazidi, M, Mcalinden, C, Mehata, S, Mehndiratta, M, Memish, Z, Mendoza, W, Mengistie, M, Mensah, G, Meretoja, A, Mezgebe, H, Miller, T, Mishra, S, Ibrahim, N, Mohammadi, A, Mohammed, K, Mohammed, S, Mokdad, A, Moradi-Lakeh, M, Velasquez, I, Musa, K, Naghavi, M, Ngunjiri, J, Nguyen, C, Nguyen, G, Le Nguyen, Q, Nguyen, T, Nichols, E, Ningrum, D, Nong, V, Norrving, B, Noubiap, J, Ogbo, F, Owolabi, M, Pandian, J, Petzold, M, Phillips, M, Piradov, M, Poulton, R, Pourmalek, F, Qorbani, M, Rafay, A, Rahman, M, Rai, R, Rajsic, S, Ranta, A, Rawaf, S, Renzaho, A, Rezai, M, Roshandel, G, Rubagotti, E, Sachdev, P, Safiri, S, Sahathevan, R, Sahraian, M, Samy, A, Santalucia, P, Santos, I, Sartorius, B, Satpathy, M, Sawhney, M, Saylan, M, Sepanlou, S, Shaikh, M, Shakir, R, Shamsizadeh, M, Sheth, K, Shigematsu, M, Shoman, H, Silva, D, Smith, M, Sobngwi, E, Sposato, L, Stein, D, Steiner, T, Stovner, L, Abdulkader, R, EI Szoeke, C, Tabarés-Seisdedos, R, Tanne, D, Theadom, A, Thrift, A, Tirschwell, D, Topor-Madry, R, Tran, B, Truelsen, T, Tuem, K, Ukwaja, K, Uthman, O, Varakin, Y, Vasankari, T, Venketasubramanian, N, Vlassov, V, Wadilo, F, Wakayo, T, Wallin, M, Weiderpass, E, Westerman, R, Wijeratne, T, Wiysonge, C, Woldu, M, Wolfe, C, Xavier, D, Xu, G, Yano, Y, Yimam, H, Yonemoto, N, Yu, C, Zaidi, Z, El Sayed Zaki, M, Zunt, J, Murray, C, and Vos, T

Subjects
Cost of Illness, Nutrition and Disease, GBD, Voeding en Ziekte, Humans, Life Science, Quality-Adjusted Life Years, Nervous System Diseases, Global Health, Article, Global Burden of Disease, VLAG
Abstract

Background Comparable data on the global and country-specific burden of neurological disorders and their trends are\ud crucial for health-care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors\ud (GBD) Study provides such information but does not routinely aggregate results that are of interest to clinicians\ud specialising in neurological conditions. In this systematic analysis, we quantified the global disease burden due to\ud neurological disorders in 2015 and its relationship with country development level.\ud \ud Methods We estimated global and country-specific prevalence, mortality, disability-adjusted life-years (DALYs), years\ud of life lost (YLLs), and years lived with disability (YLDs) for various neurological disorders that in the GBD classification\ud have been previously spread across multiple disease groupings. The more inclusive grouping of neurological\ud disorders included stroke, meningitis, encephalitis, tetanus, Alzheimer’s disease and other dementias, Parkinson’s\ud disease, epilepsy, multiple sclerosis, motor neuron disease, migraine, tension-type headache, medication overuse\ud headache, brain and nervous system cancers, and a residual category of other neurological disorders. We also analysed\ud results based on the Socio-demographic Index (SDI), a compound measure of income per capita, education, and\ud fertility, to identify patterns associated with development and how countries fare against expected outcomes relative\ud to their level of development.\ud \ud Findings Neurological disorders ranked as the leading cause group of DALYs in 2015 (250·7 [95% uncertainty interval\ud (UI) 229·1 to 274·7] million, comprising 10·2% of global DALYs) and the second-leading cause group of deaths (9·4\ud [9·1 to 9·7] million], comprising 16·8% of global deaths). The most prevalent neurological disorders were tensiontype\ud headache (1505·9 [UI 1337·3 to 1681·6 million cases]), migraine (958·8 [872·1 to 1055·6] million), medication\ud overuse headache (58·5 [50·8 to 67·4 million]), and Alzheimer’s disease and other dementias (46·0\ud [40·2 to 52·7 million]). Between 1990 and 2015, the number of deaths from neurological disorders increased by\ud 36·7%, and the number of DALYs by 7·4%. These increases occurred despite decreases in age-standardised rates of\ud death and DALYs of 26·1% and 29·7%, respectively; stroke and communicable neurological disorders were\ud responsible for most of these decreases. Communicable neurological disorders were the largest cause of DALYs in\ud countries with low SDI. Stroke rates were highest at middle levels of SDI and lowest at the highest SDI. Most of the\ud changes in DALY rates of neurological disorders with development were driven by changes in YLLs.\ud \ud Interpretation Neurological disorders are an important cause of disability and death worldwide. Globally, the burden\ud of neurological disorders has increased substantially over the past 25 years because of expanding population numbers\ud and ageing, despite substantial decreases in mortality rates from stroke and communicable neurological disorders.\ud The number of patients who will need care by clinicians with expertise in neurological conditions will continue to\ud grow in coming decades. Policy makers and health-care providers should be aware of these trends to provide adequate\ud services.\ud \ud Funding Bill & Melinda Gates Foundation.

Published
2017

16. Influence of Renal Impairment on Outcome for Thrombolysis-Treated Acute Ischemic Stroke: ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study) Post Hoc Analysis

Author

Carr, SJ, Wang, X, Olavarria, VV, Lavados, PM, Rodriguez, JA, Kim, JS, Lee, TH, Lindley, RI, Pontes-Neto, OM, Ricci, S, Sato, S, Sharma, VK, Woodward, M, Chalmers, J, Anderson, CS, Robinson, TG, Carr, SJ, Wang, X, Olavarria, VV, Lavados, PM, Rodriguez, JA, Kim, JS, Lee, TH, Lindley, RI, Pontes-Neto, OM, Ricci, S, Sato, S, Sharma, VK, Woodward, M, Chalmers, J, Anderson, CS, and Robinson, TG

Abstract

Background and Purpose - Renal dysfunction (RD) is associated with poor prognosis after stroke. We assessed the effects of RD on outcomes and interaction with low- versus standard-dose alteplase in a post hoc subgroup analysis of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study). Methods - A total of 3220 thrombolysis-eligible patients with acute ischemic stroke (mean age, 66.5 years; 37.8% women) were randomly assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) intravenous alteplase within 4.5 hours of symptom onset. Six hundred and fifty-nine (19.8%) patients had moderate-to-severe RD (estimated glomerular filtration rate, <60 mL/min per 1.73 m2) at baseline. The impact of RD on death or disability (modified Rankin Scale scores, 2-6) at 90 days, and symptomatic intracerebral hemorrhage, was assessed in logistic regression models. Results - Compared with patients with normal renal function (>90 mL/min per 1.73 m2), those with severe RD (<30 mL/min per 1.73 m2) had increased mortality (adjusted odds ratio, 2.07; 95% confidence interval, 0.89-4.82; P=0.04 for trend); every 10 mL/min per 1.73 m2 lower estimated glomerular filtration rate was associated with an adjusted 9% increased odds of death from thrombolysis-treated acute ischemic stroke. There was no significant association with modified Rankin Scale scores 2 to 6 (adjusted odds ratio, 1.03; 95% confidence interval, 0.62-1.70; P=0.81 for trend), modified Rankin Scale 3 to 6 (adjusted odds ratio, 1.20; 95% confidence interval, 0.72-2.01; P=0.44 for trend), or symptomatic intracerebral hemorrhage, or any heterogeneity in comparative treatment effects between low-dose and standard-dose alteplase by RD grades. Conclusions - RD is associated with increased mortality but not disability or symptomatic intracerebral hemorrhage in thrombolysis-eligible and treated acute ischemic stroke patients. Uncertainty persists as to whether low-dose alteplase confers benefits over standard-dos

Published
2017

17. Intracerebral hemorrhage location and outcome among INTERACT2 participants

Author

Delcourt, C, Sato, S, Zhang, S, Sandset, EC, Zheng, D, Chen, X, Hackett, ML, Arima, H, Hata, J, Heeley, E, Salman, RAS, Robinson, T, Davies, L, Lavados, PM, Lindley, RI, Stapf, C, Chalmers, J, Anderson, CS, Delcourt, C, Sato, S, Zhang, S, Sandset, EC, Zheng, D, Chen, X, Hackett, ML, Arima, H, Hata, J, Heeley, E, Salman, RAS, Robinson, T, Davies, L, Lavados, PM, Lindley, RI, Stapf, C, Chalmers, J, and Anderson, CS

Abstract

Objective: To clarify associations between intracerebral hemorrhage (ICH) location and clinical outcomes among participants of the main phase Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). Methods: Associations between ICH sites and poor outcomes (death [6] or major disability [3-5] of modified Rankin Scale) and European Quality of Life Scale (EQ-5D) utility scores at 90 days were assessed in logistic regression models. Results: Of 2,066 patients included in the analyses, associations were identified between ICH sites and poor outcomes: Involvement of posterior limb of internal capsule increased risks of death or major disability (odds ratio [OR] 2.10) and disability (OR 1.81); thalamic involvement increased risks of death or major disability (OR 2.24) and death (OR 1.97). Involvement of the posterior limb of the internal capsule, thalamus, and infratentorial sites were each associated with poor EQ-5D utility score (≤0.7 [median]; OR 1.87, 2.14, and 2.81, respectively). Posterior limb of internal capsule involvement was strongly associated with low scores across all health-related quality of life domains. ICH encompassing the thalamus and posterior limb of internal capsule were associated with death or major disability, major disability, and poor EQ-5D utility score (OR 1.72, 2.26, and 1.71, respectively). Conclusion: Poor clinical outcomes are related to ICH affecting the posterior limb of internal capsule, thalamus, and infratentorial sites. The highest association with death or major disability and poor EQ-5D utility score was seen in ICH encompassing the thalamus and posterior limb of internal capsule. ClinicalTrials.gov registration: NCT00716079.

Published
2017

18. Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970-2016: a systematic analysis for the Global Burden of Disease Study 2016

Author

Wang, H, Abajobir, AA, Abate, KH, Abbafati, C, Abbas, KM, Abd-Allah, F, Abera, SF, Abraha, HN, Abu-Raddad, LJ, Abu-Rmeileh, NME, Adedeji, IA, Adedoyin, RA, Adetifa, IMO, Adetokunboh, O, Afshin, A, Aggarwal, R, Agrawal, A, Agrawal, S, Kiadaliri, AA, Ahmed, MB, Aichour, AN, Aichour, I, Aichour, MTE, Aiyar, S, Akanda, S, Akinyemiju, TF, Akseer, N, Al-Eyadhy, A, Al Lami, FH, Alabed, S, Alahdab, F, Al-Aly, Z, Alam, K, Alam, N, Alasfoor, D, Aldridge, RW, Alene, KA, Alhabib, S, Ali, R, Alizadeh-Navaei, R, Aljunid, SM, Alkaabi, JM, Alkerwi, A, Alla, F, Allam, SD, Allebeck, P, Al-Raddadi, R, Alsharif, U, Altirkawi, KA, Martin, EA, Alvis-Guzman, N, Amare, AT, Ameh, EA, Amini, E, Ammar, W, Amoako, YA, Anber, N, Andrei, CL, Androudi, S, Ansari, H, Ansha, MG, Antonio, CAT, Anwari, P, Arnlov, J, Arora, M, Al, A, Aryal, KK, Asayesh, H, Asgedom, SW, Asghar, RJ, Assadi, R, Atey, TM, Atre, SR, Avila-Burgos, L, Avokpaho, EFGA, Awasthi, A, Quintanilla, BPA, Babalola, TK, Bacha, U, Badawi, A, Balakrishnan, K, Balalla, S, Barac, A, Barber, RM, Barboza, MA, Barker-Collo, SL, Barnighausen, T, Barquera, S, Barregard, L, Barrero, LH, Baune, BT, Bazargan-Hejazi, S, Bedi, N, Beghi, E, Bejot, Y, Bekele, BB, Bell, ML, Bello, AK, Bennett, DA, Bennett, JR, Bensenor, IM, Benson, J, Berhane, A, Berhe, DF, Bernabe, E, Beuran, M, Beyene, AS, Bhala, N, Bhansali, A, Bhaumik, S, Bhutta, ZA, Bikbov, B, Birungi, C, Biryukov, S, Bisanzio, D, Bizuayehu, HM, Bjerregaard, P, Blosser, CD, Boneya, DJ, Boufous, S, Bourne, RRA, Brazinova, A, Breitborde, NJK, Brenner, H, Brugha, TS, Bukhman, G, Negesa, L, Bulto, B, Bumgarner, BR, Burch, M, Butt, ZA, Cahill, LE, Cahuana-Hurtado, L, Campos-Nonato, IR, Car, J, Car, M, Crdenas, R, Carpenter, DO, Carrero, JJ, Carter, A, Castaneda-Orjuela, CA, Rivas, JC, Castro, FF, Castro, RE, Catala-Lopez, F, Chen, H, Chiang, PP-C, Chibalabala, M, Chisumpa, VH, Chitheer, AA, Choi, J-YJ, Christensen, H, Christopher, DJ, Ciobanu, LG, Cirillo, M, Cohen, AJ, Colquhoun, SM, Coresh, J, 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Malta, DC, Mantovani, LG, Manyazewal, T, Mapoma, CC, Marczak, LB, Marks, GB, Martinez-Raga, J, Martins-Melo, FR, Massano, J, Maulik, PK, Mayosi, BM, Mazidi, M, McAlinden, C, McGarvey, ST, McGrath, JJ, Mckee, M, Mehata, S, Mehndiratta, MM, Mehta, KM, Meier, T, Mekonnen, TC, Meles, KG, Memiah, P, Memish, ZA, Mendoza, W, Mengesha, MM, Mengistie, MA, Tadese, D, Menon, MGR, Menota, BG, Mensah, GA, Meretoja, A, Meretoja, TJ, Mezgebe, HB, Micha, R, Mikesell, J, Miller, TR, Mills, EJ, Minnig, S, Mirarefin, M, Mirrakhimov, EM, Misganaw, A, Mishra, SR, Mohammad, KA, Mohammadi, A, Mohammed, KESM, Mohan, MBV, Mohanty, SK, Mokdad, AH, Assaye, AM, Mollenkopf, SK, Molokhia, M, Monasta, L, Hernandez, JCM, Montico, M, Mooney, MD, Moore, AR, Moradi-Lakeh, M, Moraga, P, Morawska, L, Velasquez, IM, Mori, R, Morrison, SD, Mruts, KB, Mueller, UO, Mullany, E, Muller, K, Venkata, G, Murthy, S, Musa, KI, Nachega, JB, Nagata, C, Nagel, G, Naghavi, M, Naidoo, KS, Nanda, L, Nangia, V, Nascimento, BR, Natarajan, G, Negoi, I, Cuong, TN, Ningrum, DNA, Nisar, MI, Nomura, M, Vuong, MN, Norheim, OF, Norrving, B, Noubiap, JJN, Nyakarahuka, L, Obermeyer, CM, O'Donnell, MJ, Ogbo, FA, Oh, I-H, Okoro, A, Oladimeji, O, Olagunju, AT, Olusanya, BO, Olusanya, JO, Oren, E, Ortiz, A, Osgood-Zimmerman, A, Ota, E, Owolabi, MO, Oyekale, AS, Pa, M, Pacella, RE, Pakhale, S, Pana, A, Panda, BK, Panda-Jonas, S, Park, E-K, Parsaeian, M, Patel, T, Patten, SB, Patton, GC, Paudel, D, Pereira, DM, Perez-Padilla, R, Perez-Ruiz, F, Perico, N, Pervaiz, A, Pesudovs, K, Peterson, CB, Petri, WA, Petzold, M, Phillips, MR, Piel, FB, Pigott, DM, Pishgar, F, Plass, D, Polinder, S, Popova, S, Postma, MJ, Poulton, RG, Pourmalek, F, Prasad, N, Purwar, M, Qorbani, M, Rabiee, RHS, Radfar, A, Rafay, A, Rahimi-Movaghar, A, Rahimi-Movaghar, V, Rahman, M, Rahman, MHU, Rahman, SU, Rai, RK, Rajsic, S, Ram, U, Rana, SM, Ranabhat, CL, Rao, PV, Rawaf, S, Ray, SE, Rego, MAS, Rehm, J, Reiner, RC, Remuzzi, G, Renzaho, AMNN, Resnikoff, S, Rezaei, S, Rezai, MS, Ribeiro, AL, Rokni, MB, Ronfani, L, Roshandel, G, Roth, GA, Rothenbacher, D, Roy, A, Rubagotti, E, Ruhago, GM, Saadat, S, Sabde, YD, Sachdev, PS, Sadat, N, Safdarian, M, Safiri, SSS, Sagar, R, Sahathevan, R, Sahebkar, A, Sahraian, MA, Salama, J, Salamati, P, Salomon, JA, Salvi, SS, Samy, AM, Sanabria, JR, Sanchez-Nino, MD, Santos, IS, Milicevic, MMS, Sarmiento-Suarez, R, Sartorius, B, Satpathy, M, Sawhney, M, Saxena, S, Saylan, MI, Schmidt, MI, Schneider, IJC, Schutte, AE, Schwebel, DC, Schwendicke, F, Seedat, S, Seid, AM, Sepanlou, SG, Servan-Mori, EE, Shackelford, KA, Shaheen, A, Shahraz, S, Shaikh, MA, Shamsipour, M, Shamsizadeh, M, Islam, SMS, Sharma, J, Sharma, R, She, J, Shen, J, Shetty, BP, Shi, P, Shibuya, K, Shigematsu, M, Shiri, R, Shiue, I, Shrime, MG, Sigfusdottir, ID, Silberberg, DH, Silpakit, N, Silva, DAS, Silva, JP, Silveira, DGA, Sindi, S, Singh, A, Singh, JA, Singh, PK, Singh, V, Sinha, DN, Skiadaresi, E, Sligar, A, Smith, DL, Sobaih, BHA, Sobngwi, E, Soneji, S, Soriano, JB, Sreeramareddy, CT, Srinivasan, V, Stathopoulou, V, Steel, N, Stein, DJ, Steiner, C, Stockl, H, Stokes, MA, Strong, M, Sufiyan, MB, Suliankatchi, RA, Sunguya, BF, Sur, PJ, Swaminathan, S, Sykes, BL, Szoeke, CEI, Tabares-Seisdedos, R, Tadakamadla, SK, Tadese, F, Tandon, N, Tanne, D, Tarajia, M, Tavakkoli, M, Taveira, N, Tehrani-Banihashemi, A, Tekelab, T, Tekle, DY, Shifa, GT, Temsah, M-H, Terkawi, AS, Tesema, CL, Tesssema, B, Theis, A, Thomas, N, Thompson, AH, Thomson, AJ, Thrift, AG, Tiruye, TY, Tobe-Gai, R, Tonelli, M, Topor-Madry, R, Topouzis, F, Tortajada, M, Tran, BX, Trujillo, TTU, Tsilimparis, N, Tuem, KB, Tuzcu, EM, Tyrovolas, S, Ukwaja, KN, Undurraga, EA, Uthman, OA, Uzochukwu, BSC, van Boven, JFM, Varakin, YY, Varughese, S, Vasankari, T, Vasconcelos, AMN, Venketasubramanian, N, Vidavalur, R, Violante, FS, Vishnu, A, Vladimirov, SK, Vlassov, VV, Vollset, SE, Vos, T, Waid, JL, Wakayo, T, Wang, Y-P, Weichenthal, S, Weiderpass, E, Weintraub, RG, Werdecker, A, Wesana, J, Wijeratne, T, Wilkinson, JD, Wiysonge, CS, Woldeyes, BG, Wolfe, CDA, Workicho, A, Workie, SB, Xavier, D, Xu, G, Yaghoubi, M, Yakob, B, Yalew, AZ, Yan, LL, Yano, Y, Yaseri, M, Ye, P, Yimam, HH, Yip, P, Yirsaw, BD, Yonemoto, N, Yoon, S-J, Yotebieng, M, Younis, MZ, Zaidi, Z, Zaki, MES, Zeeb, H, Zenebe, ZM, Zerfu, TA, Zhang, AL, Zhang, X, Zodpey, S, Zuhlke, LJ, Lopez, AD, and Murray, CJL

Published
2017

19. Frequency, determinants, and effects of early seizures after thrombolysis for acute ischemic stroke: The ENCHANTED trial

Author

Xu, Y, Hackett, ML, Chalmers, J, Lindley, RI, Wang, X, Li, Q, Robinson, T, Arima, H, Lavados, PM, Anderson, CS, Xu, Y, Hackett, ML, Chalmers, J, Lindley, RI, Wang, X, Li, Q, Robinson, T, Arima, H, Lavados, PM, and Anderson, CS

Abstract

Background: Seizures after ischemic stroke have not been well-studied. We aim to determine the frequency, determinants, and significance of early seizures after thrombolysis for acute ischemic stroke. Methods: Data are from the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED), an international, multicenter, randomized controlled trial where patients with acute ischemic stroke were randomized to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) IV alteplase. The protocol prespecified prospective data collection on in-hospital seizures over 7 days postrandomization. Logistic regression models were used to determine variables associated with seizures and their significance on poor outcomes of death or disability (modified Rankin scale scores 3-6), symptomatic intracerebral hemorrhage (sICH), and European Quality of Life 5-Dimensions questionnaire [EQ-5D] over 90 days. Results: Data were available for 3,139 acute ischemic stroke participants, of whom 42 (1.3%) had seizures at a median 22.7 hours after the onset of symptoms. Baseline variables associated with seizures were male sex (odds ratio [OR] 2.19, 95% confidence interval [CI] 1.07-4.50), severe neurologic impairment (NIH Stroke Scale score ≥10; OR 2.16, 95% CI 1.06-4.40), and fever (OR 4.55, 95% CI 2.37-8.71). Seizures independently predicted poor recovery: death or major disability (OR 2.88, 95% CI 1.28-6.47), unfavorable ordinal shift of mRS scores (OR 1.94, 95% CI 1.10-3.39), and lower than median EQ-5D health utility index score (OR 3.50, 95% CI 1.37-8.91). There was no association of seizures with sICH in adjusted analysis. Conclusions: In thrombolysis-treated patients with acute ischemic stroke, seizures are uncommon, occur early, and predict poor recovery.

Published
2017

20. Practice patterns for neurosurgical utilization and outcome in acute intracerebral hemorrhage: Intensive blood pressure reduction in acute cerebral hemorrhage trials 1 and 2 studies

Author

Guo, R, Blacker, DJ, Wang, X, Arima, H, Lavados, PM, Lindley, RI, Chalmers, J, Anderson, CS, Robinson, T, Guo, R, Blacker, DJ, Wang, X, Arima, H, Lavados, PM, Lindley, RI, Chalmers, J, Anderson, CS, and Robinson, T

Abstract

Background: The prognosis in acute spontaneous intracerebral hemorrhage (ICH) is related to hematoma volume, where >30 mL is commonly used to define large ICH as a threshold for neurosurgical decompression but without clear supporting evidence. Objective: To determine the factors associated with large ICH and neurosurgical intervention among participants of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials (INTERACT). Methods: We performed pooled analysis of the pilot INTERACT1 (n = 404) and main INTERACT2 (n = 2839) studies of ICH patients (<6 h of onset) with elevated systolic blood pressure (SBP, 150-220mmHg)whowere randomized to intensive (target SBP<140mmHg) or contemporaneous guideline-recommended (target SBP < 180 mm Hg) management. Neurosurgical intervention data were collected at 7 d postrandomization. Multivariable logistic regression was used to determine associations. Results: There were 372 (13%) patients with large ICH volume (>30 mL), which was associated with nonresiding in China, nondiabetic status, severe neurological deficit (National Institutes of Health stroke scale [NIHSS] score ≥ 15), lobar location, intraventricular hemorrhage extension, raised leucocyte count, and hyponatremia. Significant predictors of those patients who underwent surgery (226 of 3233 patients overall; 83 of 372 patients with large ICH) were younger age, severe neurological deficit (lower Glasgow coma scale score, and NIHSS score≥15), baseline ICH volume>30 mL, and intraventricular hemorrhage. Conclusion: Early identification of severe ICH, based on age and clinical and imaging parameters, may facilitate neurosurgery and intensive monitoring of patients.

Published
2017

21. Characteristics, management and response to alteplase in China versus non-China participants of the ENCHANTED trial

Author

Song, L, Wang, X, Robinson, T, Lindley, RI, Arima, H, Lavados, PM, Chen, X, Chalmers, J, Anderson, CS, Song, L, Wang, X, Robinson, T, Lindley, RI, Arima, H, Lavados, PM, Chen, X, Chalmers, J, and Anderson, CS

Abstract

Background The characteristics of patients with acute ischaemic stroke (AIS) and their management vary across regions, which may influence outcomes. We examined for differential patterns of outcome between China and non- China participants of the ENhanced Control of Hypertension And Thrombolysis strokE stuDy (ENCHANTED), which tested different alteplase doses in AIS. Methods ENCHANTED was an international, multicentre, open, blinded-endpoint trial of the effects of low-dose (0.6 mg/kg) versus standard-dose (0.9 mg/kg) intravenous alteplase on 90-day disability outcomes and symptomatic intracerebral haemorrhage (sICH) in 3310 patients with AIS. Results Participants (n=1419, 48%) in China were younger, and more often male, hypertensive and with prior stroke and coronary artery disease, but less likely to have atrial fibrillation and use antihypertensive, antithrombotic and lipid-lowering agents, compared with non-China patients with AIS. Although China participants had more AIS due to large artery occlusion, were treated later and had differing ancillary management, there was no significant difference in 90-day modified Rankin scale scores 2-6 (55.6% vs 47.8%; OR, adjusted for baseline and management factors 0.87 (95% CI 0.71 to 1.07; p=0.20)) and risk of sICH (Safe Implementation of Thrombolysis in Stroke-Monitoring Study criteria: 1.4% vs 1.8%; p=0.12) compared with non-China participants. There was no heterogeneity in the treatment effects of low-dose versus standard-dose alteplase between China and non-China participants. Conclusion Patients with AIS recruited to the ENCHANTED trial in China had similar outcomes in response to thrombolysis treatment despite significantly differing demographic, clinical and management factors to patients with AIS in other regions.

Published
2017

22. Global, regional, and national burden of neurological disorders during 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

Author

Feigin, V, Abajobir, A, Abate, K, Abd-Allah, F, Abdulle, A, Abera, S, Abyu, G, Ahmed, M, Aichour, A, Aichour, I, Aichour, M, Akinyemi, R, Alabed, S, Al-Raddadi, R, Alvis-Guzman, N, Amare, A, Ansari, H, Anwari, P, Ärnlöv, J, Asayesh, H, Asgedom, S, Atey, T, Avila-Burgos, L, Frinel, E, Avokpaho, G, Barac, A, Barboza, M, Barker-Collo, S, Bärnighausen, T, Bedi, N, Beghi, E, Bennett, D, Bensenor, I, Berhane, A, Betsu, B, Bhaumik, S, Birlik, S, Biryukov, S, Boneya, D, Bulto, L, Carabin, H, Casey, D, Castañeda-Orjuela, C, Catalá-López, F, Chen, H, Chitheer, A, Chowdhury, R, Christensen, H, Dandona, L, Dandona, R, Veber, G, Dharmaratne, S, Do, H, Dokova, K, Dorsey, E, Ellenbogen, R, Eskandarieh, S, Farvid, M, Fereshtehnejad, S, Fischer, F, Foreman, K, Geleijnse, J, Gillum, R, Giussani, G, Gona, P, Goulart, A, Gugnani, H, Gupta, R, Hamadeh, R, Hambisa, M, Hankey, G, Hareri, H, Havmoeller, R, Hay, S, Heydarpour, P, Hotez, P, Jakovljevic, M, Javanbakht, M, Jeemon, P, Jonas, J, Kalkonde, Y, Kandel, A, Karch, A, Kasaeian, A, Kastor, A, Keiyoro, P, Khader, Y, Khalil, I, Khan, E, Khang, Y, Tawfih, A, Khoja, A, Khubchandani, J, Kim, D, Kim, Y, Kivimaki, M, Kokubo, Y, Kosen, S, Kravchenko, M, Krishnamurthi, R, Defo, B, Kumar, G, Kumar, R, Kyu, H, Larsson, A, Lavados, P, Li, Y, Liang, X, Liben, M, Lo, W, Logroscino, G, Lotufo, P, Loy, C, Mackay, M, El Razek, H, El Razek, M, Majeed, A, Malekzadeh, R, Manhertz, T, Mantovani, L, Massano, J, Mazidi, M, Mcalinden, C, Mehata, S, Mehndiratta, M, Memish, Z, Mendoza, W, Mengistie, M, Mensah, G, Meretoja, A, Mezgebe, H, Miller, T, Mishra, S, Ibrahim, N, Mohammadi, A, Mohammed, K, Mohammed, S, Mokdad, A, Moradi-Lakeh, M, Velasquez, I, Musa, K, Naghavi, M, Ngunjiri, J, Nguyen, C, Nguyen, G, Le Nguyen, Q, Nguyen, T, Nichols, E, Ningrum, D, Nong, V, Norrving, B, Noubiap, J, Ogbo, F, Owolabi, M, Pandian, J, Petzold, M, Phillips, M, Piradov, M, Poulton, R, Pourmalek, F, Qorbani, M, Rafay, A, Rahman, M, Rai, R, Rajsic, S, Ranta, A, Rawaf, S, Renzaho, A, Rezai, M, Roshandel, G, Rubagotti, E, Sachdev, P, Safiri, S, Sahathevan, R, Sahraian, M, Samy, A, Santalucia, P, Santos, I, Sartorius, B, Satpathy, M, Sawhney, M, Saylan, M, Sepanlou, S, Shaikh, M, Shakir, R, Shamsizadeh, M, Sheth, K, Shigematsu, M, Shoman, H, Silva, D, Smith, M, Sobngwi, E, Sposato, L, Stein, D, Steiner, T, Stovner, L, Abdulkader, R, EI Szoeke, C, Tabarés-Seisdedos, R, Tanne, D, Theadom, A, Thrift, A, Tirschwell, D, Topor-Madry, R, Tran, B, Truelsen, T, Tuem, K, Ukwaja, K, Uthman, O, Varakin, Y, Vasankari, T, Venketasubramanian, N, Vlassov, V, Wadilo, F, Wakayo, T, Wallin, M, Weiderpass, E, Westerman, R, Wijeratne, T, Wiysonge, C, Woldu, M, Wolfe, C, Xavier, D, Xu, G, Yano, Y, Yimam, H, Yonemoto, N, Yu, C, Zaidi, Z, El Sayed Zaki, M, Zunt, J, Murray, C, Vos, T, Feigin, VL, Abajobir, AA, Abate, KH, Abdulle, AM, Abera, SF, Abyu, GY, Ahmed, MB, Aichour, AN, Aichour, MTE, Akinyemi, RO, Amare, AT, Asgedom, SW, Atey, TM, Avokpaho, GA, Barker-Collo, SL, Bennett, DA, Bensenor, IM, Betsu, BD, Birlik, SM, Boneya, DJ, Bulto, LNB, Castañeda-Orjuela, CA, Chitheer, AA, Veber, GA, Dharmaratne, SD, Do, HP, Dorsey, ER, Ellenbogen, RG, Farvid, MS, Fereshtehnejad, SM, Foreman, KJ, Geleijnse, JM, Gillum, RF, Gona, PN, Goulart, AC, Gugnani, HC, Hamadeh, RR, Hankey, GJ, Hareri, HA, Hay, SI, Hotez, PJ, Jakovljevic, MMB, Jonas, JB, Keiyoro, PN, Khader, YS, Khalil, IA, Khan, EA, Khang, YH, Kim, YJ, Krishnamurthi, RV, Defo, BK, Kumar, GA, Kyu, HH, Lavados, PM, Liben, ML, Lo, WD, Lotufo, PA, Loy, CT, Mackay, MT, El Razek, HMA, El Razek, MMA, Mantovani, LG, McAlinden, C, Mehndiratta, MM, Memish, ZA, Mengistie, MA, Mensah, GA, Mezgebe, HB, Miller, TR, Mishra, SR, Ibrahim, NM, Mohammed, KE, Mokdad, AH, Velasquez, IM, Musa, KI, Ngunjiri, JW, Nguyen, CT, Nguyen, TH, Ningrum, DNA, Nong, VM, Noubiap, JJN, Ogbo, FA, Owolabi, MO, Pandian, JD, Phillips, MR, Piradov, MA, Poulton, RG, Rahman, MH, Rai, RK, Renzaho, AMN, Rezai, MS, Sahraian, MA, Samy, AM, Santos, IS, Saylan, MI, Sepanlou, SG, Shaikh, MA, Sheth, KN, Silva, DAS, Sposato, LA, Stein, DJ, Steiner, TJ, Stovner, LJ, Abdulkader, RS, Theadom, AM, Thrift, AG, Tirschwell, DL, Tran, BX, Tuem, KB, Ukwaja, KN, Uthman, OA, Varakin, YY, Vlassov, VV, Wallin, MT, Wiysonge, CS, Woldu, MA, Wolfe, CDA, Yimam, HH, Zunt, JR, Murray, CJL, Feigin, V, Abajobir, A, Abate, K, Abd-Allah, F, Abdulle, A, Abera, S, Abyu, G, Ahmed, M, Aichour, A, Aichour, I, Aichour, M, Akinyemi, R, Alabed, S, Al-Raddadi, R, Alvis-Guzman, N, Amare, A, Ansari, H, Anwari, P, Ärnlöv, J, Asayesh, H, Asgedom, S, Atey, T, Avila-Burgos, L, Frinel, E, Avokpaho, G, Barac, A, Barboza, M, Barker-Collo, S, Bärnighausen, T, Bedi, N, Beghi, E, Bennett, D, Bensenor, I, Berhane, A, Betsu, B, Bhaumik, S, Birlik, S, Biryukov, S, Boneya, D, Bulto, L, Carabin, H, Casey, D, Castañeda-Orjuela, C, Catalá-López, F, Chen, H, Chitheer, A, Chowdhury, R, Christensen, H, Dandona, L, Dandona, R, Veber, G, Dharmaratne, S, Do, H, Dokova, K, Dorsey, E, Ellenbogen, R, Eskandarieh, S, Farvid, M, Fereshtehnejad, S, Fischer, F, Foreman, K, Geleijnse, J, Gillum, R, Giussani, G, Gona, P, Goulart, A, Gugnani, H, Gupta, R, Hamadeh, R, Hambisa, M, Hankey, G, Hareri, H, Havmoeller, R, Hay, S, Heydarpour, P, Hotez, P, Jakovljevic, M, Javanbakht, M, Jeemon, P, Jonas, J, Kalkonde, Y, Kandel, A, Karch, A, Kasaeian, A, Kastor, A, Keiyoro, P, Khader, Y, Khalil, I, Khan, E, Khang, Y, Tawfih, A, Khoja, A, Khubchandani, J, Kim, D, Kim, Y, Kivimaki, M, Kokubo, Y, Kosen, S, Kravchenko, M, Krishnamurthi, R, Defo, B, Kumar, G, Kumar, R, Kyu, H, Larsson, A, Lavados, P, Li, Y, Liang, X, Liben, M, Lo, W, Logroscino, G, Lotufo, P, Loy, C, Mackay, M, El Razek, H, El Razek, M, Majeed, A, Malekzadeh, R, Manhertz, T, Mantovani, L, Massano, J, Mazidi, M, Mcalinden, C, Mehata, S, Mehndiratta, M, Memish, Z, Mendoza, W, Mengistie, M, Mensah, G, Meretoja, A, Mezgebe, H, Miller, T, Mishra, S, Ibrahim, N, Mohammadi, A, Mohammed, K, Mohammed, S, Mokdad, A, Moradi-Lakeh, M, Velasquez, I, Musa, K, Naghavi, M, Ngunjiri, J, Nguyen, C, Nguyen, G, Le Nguyen, Q, Nguyen, T, Nichols, E, Ningrum, D, Nong, V, Norrving, B, Noubiap, J, Ogbo, F, Owolabi, M, Pandian, J, Petzold, M, Phillips, M, Piradov, M, Poulton, R, Pourmalek, F, Qorbani, M, Rafay, A, Rahman, M, Rai, R, Rajsic, S, Ranta, A, Rawaf, S, Renzaho, A, Rezai, M, Roshandel, G, Rubagotti, E, Sachdev, P, Safiri, S, Sahathevan, R, Sahraian, M, Samy, A, Santalucia, P, Santos, I, Sartorius, B, Satpathy, M, Sawhney, M, Saylan, M, Sepanlou, S, Shaikh, M, Shakir, R, Shamsizadeh, M, Sheth, K, Shigematsu, M, Shoman, H, Silva, D, Smith, M, Sobngwi, E, Sposato, L, Stein, D, Steiner, T, Stovner, L, Abdulkader, R, EI Szoeke, C, Tabarés-Seisdedos, R, Tanne, D, Theadom, A, Thrift, A, Tirschwell, D, Topor-Madry, R, Tran, B, Truelsen, T, Tuem, K, Ukwaja, K, Uthman, O, Varakin, Y, Vasankari, T, Venketasubramanian, N, Vlassov, V, Wadilo, F, Wakayo, T, Wallin, M, Weiderpass, E, Westerman, R, Wijeratne, T, Wiysonge, C, Woldu, M, Wolfe, C, Xavier, D, Xu, G, Yano, Y, Yimam, H, Yonemoto, N, Yu, C, Zaidi, Z, El Sayed Zaki, M, Zunt, J, Murray, C, Vos, T, Feigin, VL, Abajobir, AA, Abate, KH, Abdulle, AM, Abera, SF, Abyu, GY, Ahmed, MB, Aichour, AN, Aichour, MTE, Akinyemi, RO, Amare, AT, Asgedom, SW, Atey, TM, Avokpaho, GA, Barker-Collo, SL, Bennett, DA, Bensenor, IM, Betsu, BD, Birlik, SM, Boneya, DJ, Bulto, LNB, Castañeda-Orjuela, CA, Chitheer, AA, Veber, GA, Dharmaratne, SD, Do, HP, Dorsey, ER, Ellenbogen, RG, Farvid, MS, Fereshtehnejad, SM, Foreman, KJ, Geleijnse, JM, Gillum, RF, Gona, PN, Goulart, AC, Gugnani, HC, Hamadeh, RR, Hankey, GJ, Hareri, HA, Hay, SI, Hotez, PJ, Jakovljevic, MMB, Jonas, JB, Keiyoro, PN, Khader, YS, Khalil, IA, Khan, EA, Khang, YH, Kim, YJ, Krishnamurthi, RV, Defo, BK, Kumar, GA, Kyu, HH, Lavados, PM, Liben, ML, Lo, WD, Lotufo, PA, Loy, CT, Mackay, MT, El Razek, HMA, El Razek, MMA, Mantovani, LG, McAlinden, C, Mehndiratta, MM, Memish, ZA, Mengistie, MA, Mensah, GA, Mezgebe, HB, Miller, TR, Mishra, SR, Ibrahim, NM, Mohammed, KE, Mokdad, AH, Velasquez, IM, Musa, KI, Ngunjiri, JW, Nguyen, CT, Nguyen, TH, Ningrum, DNA, Nong, VM, Noubiap, JJN, Ogbo, FA, Owolabi, MO, Pandian, JD, Phillips, MR, Piradov, MA, Poulton, RG, Rahman, MH, Rai, RK, Renzaho, AMN, Rezai, MS, Sahraian, MA, Samy, AM, Santos, IS, Saylan, MI, Sepanlou, SG, Shaikh, MA, Sheth, KN, Silva, DAS, Sposato, LA, Stein, DJ, Steiner, TJ, Stovner, LJ, Abdulkader, RS, Theadom, AM, Thrift, AG, Tirschwell, DL, Tran, BX, Tuem, KB, Ukwaja, KN, Uthman, OA, Varakin, YY, Vlassov, VV, Wallin, MT, Wiysonge, CS, Woldu, MA, Wolfe, CDA, Yimam, HH, Zunt, JR, and Murray, CJL

Abstract

Background Comparable data on the global and country-specific burden of neurological disorders and their trends are crucial for health-care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study provides such information but does not routinely aggregate results that are of interest to clinicians specialising in neurological conditions. In this systematic analysis, we quantified the global disease burden due to neurological disorders in 2015 and its relationship with country development level. Methods We estimated global and country-specific prevalence, mortality, disability-adjusted life-years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs) for various neurological disorders that in the GBD classification have been previously spread across multiple disease groupings. The more inclusive grouping of neurological disorders included stroke, meningitis, encephalitis, tetanus, Alzheimer's disease and other dementias, Parkinson's disease, epilepsy, multiple sclerosis, motor neuron disease, migraine, tension-type headache, medication overuse headache, brain and nervous system cancers, and a residual category of other neurological disorders. We also analysed results based on the Socio-demographic Index (SDI), a compound measure of income per capita, education, and fertility, to identify patterns associated with development and how countries fare against expected outcomes relative to their level of development. Findings Neurological disorders ranked as the leading cause group of DALYs in 2015 (250·7 [95% uncertainty interval (UI) 229·1 to 274·7] million, comprising 10·2% of global DALYs) and the second-leading cause group of deaths (9·4 [9·1 to 9·7] million], comprising 16·8% of global deaths). The most prevalent neurological disorders were tension-type headache (1505·9 [UI 1337·3 to 1681·6 million cases]), migraine (958·8 [872·1 to 1055·6] million), medication overuse headache (58·5 [50·8 to 67·4 mil

Published
2017

23. Regional variation in acute stroke care organisation

Author

Muñoz Venturelli, P, Robinson, T, Lavados, PM, Olavarría, VV, Arima, H, Billot, L, Hackett, ML, Lim, JY, Middleton, S, Pontes-Neto, O, Peng, B, Cui, L, Song, L, Mead, G, Watkins, C, Lin, RT, Lee, TH, Pandian, J, de Silva, HA, Anderson, CS, Muñoz Venturelli, P, Robinson, T, Lavados, PM, Olavarría, VV, Arima, H, Billot, L, Hackett, ML, Lim, JY, Middleton, S, Pontes-Neto, O, Peng, B, Cui, L, Song, L, Mead, G, Watkins, C, Lin, RT, Lee, TH, Pandian, J, de Silva, HA, and Anderson, CS

Abstract

Background Few studies have assessed regional variation in the organisation of stroke services, particularly health care resourcing, presence of protocols and discharge planning. Our aim was to compare stroke care organisation within middle- (MIC) and high-income country (HIC) hospitals participating in the Head Position in Stroke Trial (HeadPoST). Methods HeadPoST is an on-going international multicenter crossover cluster-randomized trial of ‘sitting-up’ versus ‘lying-flat’ head positioning in acute stroke. As part of the start-up phase, one stroke care organisation questionnaire was completed at each hospital. The World Bank gross national income per capita criteria were used for classification. Results 94 hospitals from 9 countries completed the questionnaire, 51 corresponding to MIC and 43 to HIC. Most participating hospitals had a dedicated stroke care unit/ward, with access to diagnostic services and expert stroke physicians, and offering intravenous thrombolysis. There was no difference for the presence of a dedicated multidisciplinary stroke team, although greater access to a broad spectrum of rehabilitation therapists in HIC compared to MIC hospitals was observed. Significantly more patients arrived within a 4-h window of symptoms onset in HIC hospitals (41 vs. 13%; P < 0.001), and a significantly higher proportion of acute ischemic stroke patients received intravenous thrombolysis (10 vs. 5%; P = 0.002) compared to MIC hospitals. Conclusions Although all hospitals provided advanced care for people with stroke, differences were found in stroke care organisation and treatment. Future multilevel analyses aims to determine the influence of specific organisational factors on patient outcomes.

Published
2016

24. Early Blood Pressure Lowering Does Not Reduce Growth of Intraventricular Hemorrhage following Acute Intracerebral Hemorrhage: Results of the INTERACT Studies

Author

Chan, E, Anderson, CS, Wang, X, Arima, H, Saxena, A, Moullaali, TJ, Delcourt, C, Wu, G, Wang, J, Chen, G, Lavados, PM, Stapf, C, Robinson, T, Chalmers, J, Chan, E, Anderson, CS, Wang, X, Arima, H, Saxena, A, Moullaali, TJ, Delcourt, C, Wu, G, Wang, J, Chen, G, Lavados, PM, Stapf, C, Robinson, T, and Chalmers, J

Abstract

Background: Intraventricular hemorrhage (IVH) extension is common following acute intracerebral hemorrhage (ICH) and is associated with poor prognosis. Aim: To determine whether intensive blood pressure (BP)-lowering therapy reduces IVH growth. Methods: Pooled analyses of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials (INTERACT1 and INTERACT2) computed tomography (CT) substudies; multicenter, open, controlled, randomized trials of patients with acute spontaneous ICH and elevated systolic BP, randomly assigned to intensive (<140 mm Hg) or guideline-based (<180 mm Hg) BP management. Participants had blinded central analyses of baseline and 24-hour CT. Association of BP lowering to IVH growth was assessed in analysis of covariance. Results: There was no significant difference in adjusted mean IVH growth following intensive (n = 228) compared to guideline-recommended (n = 228) BP treatment (1.6 versus 2.2 ml, respectively; p = 0.56). Adjusted mean IVH growth was nonsignificantly greater in patients with a mean achieved systolic BP ≥160 mm Hg over 24 h (3.94 ml; p trend = 0.26). Conclusions: Early intensive BP-lowering treatment had no clear effect on IVH in acute ICH.

Published
2016

31. Global, regional, and national age-sex-specific mortality and life expectancy, 1950–2017: a systematic analysis for the Global Burden of Disease Study 2017

Author

Dicker, Daniel, Nguyen, Grant, Abate, Degu, Abate, Kalkidan Hassen, Abay, Solomon M, Abbafati, Cristiana, Abbasi, Nooshin, Abbastabar, Hedayat, Abd-Allah, Foad, Abdela, Jemal, Abdelalim, Ahmed, Abdel-Rahman, Omar, Abdi, Alireza, Abdollahpour, Ibrahim, Abdulkader, Rizwan Suliankatchi, Abdurahman, Ahmed Abdulahi, Abebe, Haftom Temesgen, Abebe, Molla, Abebe, Zegeye, Abebo, Teshome Abuka, Aboyans, Victor, Abraha, Haftom Niguse, Abrham, Aklilu Roba, Abu-Raddad, Laith Jamal, Abu-Rmeileh, Niveen ME, Accrombessi, Manfred Mario Kokou, Acharya, Pawan, Adebayo, Oladimeji M, Adedeji, Isaac Akinkunmi, Adedoyin, Rufus Adesoji, Adekanmbi, Victor, Adetokunboh, Olatunji O, Adhena, Beyene Meressa, Adhikari, Tara Ballav, Adib, Mina G, Adou, Arsène Kouablan, Adsuar, Jose C, Afarideh, Mohsen, Afshin, Ashkan, Agarwal, Gina, Aggarwal, Rakesh, Aghayan, Sargis Aghasi, Agrawal, Sutapa, Agrawal, Anurag, Ahmadi, Mehdi, Ahmadi, Alireza, Ahmadieh, Hamid, Ahmed, Mohamed Lemine Cheikh brahim, Ahmed, Sayem, Ahmed, Muktar Beshir, Aichour, Amani Nidhal, Aichour, Ibtihel, Aichour, Miloud Taki Eddine, Akanda, Ali S, Akbari, Mohammad Esmaeil, Akibu, Mohammed, Akinyemi, Rufus Olusola, Akinyemiju, Tomi, Akseer, Nadia, Alahdab, Fares, Al-Aly, Ziyad, Alam, Khurshid, Alebel, Animut, Aleman, Alicia V, Alene, Kefyalew Addis, Al-Eyadhy, Ayman, Ali, Raghib, Alijanzadeh, Mehran, Alizadeh-Navaei, Reza, Aljunid, Syed Mohamed, Alkerwi, Ala'a, Alla, François, Allebeck, Peter, Allen, Christine A, Alonso, Jordi, Al-Raddadi, Rajaa M, Alsharif, Ubai, Altirkawi, Khalid, Alvis-Guzman, Nelson, Amare, Azmeraw T, Amini, Erfan, Ammar, Walid, Amoako, Yaw Ampem, Anber, Nahla Hamed, Andrei, Catalina Liliana, Androudi, Sofia, Animut, Megbaru Debalkie, Anjomshoa, Mina, Anlay, Degefaye Zelalem, Ansari, Hossein, Ansariadi, Ansariadi, Ansha, Mustafa Geleto, Antonio, Carl Abelardo T, Appiah, Seth Christopher Yaw, Aremu, Olatunde, Areri, Habtamu Abera, Ärnlöv, Johan, Arora, Megha, Artaman, Al, Aryal, Krishna K, Asadi-Lari, Mohsen, Asayesh, Hamid, Asfaw, Ephrem Tsegay, Asgedom, Solomon Weldegebreal, Assadi, Reza, Ataro, Zerihun, Atey, Tesfay Mehari Mehari, Athari, Seyyed Shamsadin, Atique, Suleman, Atre, Sachin R, Atteraya, Madhu Sudhan, Attia, Engi F, Ausloos, Marcel, Avila-Burgos, Leticia, Avokpaho, Euripide F G A, Awasthi, Ashish, Awuah, Baffour, Ayala Quintanilla, Beatriz Paulina, Ayele, Henok Tadesse, Ayele, Yohanes, Ayer, Rakesh, Ayuk, Tambe B, Azzopardi, Peter S, Azzopardi-Muscat, Natasha, Badali, Hamid, Badawi, Alaa, Balakrishnan, Kalpana, Bali, Ayele Geleto, Banach, Maciej, Banstola, Amrit, Barac, Aleksandra, Barboza, Miguel A, Barquera, Simon, Barrero, Lope H, Basaleem, Huda, Bassat, Quique, Basu, Arindam, Basu, Sanjay, Baune, Bernhard T, Bazargan-Hejazi, Shahrzad, Bedi, Neeraj, Beghi, Ettore, Behzadifar, Masoud, Behzadifar, Meysam, Béjot, Yannick, Bekele, Bayu Begashaw, Belachew, Abate Bekele, Belay, Aregawi Gebreyesus, Belay, Ezra, Belay, Saba Abraham, Belay, Yihalem Abebe, Bell, Michelle L, Bello, Aminu K, Bennett, Derrick A, Bensenor, Isabela M, Berhane, Adugnaw, Berman, Adam E, Bernabe, Eduardo, Bernstein, Robert S, Bertolacci, Gregory J, Beuran, Mircea, Beyranvand, Tina, Bhala, Neeraj, Bhatia, Eesh, Bhatt, Samir, Bhattarai, Suraj, Bhaumik, Soumyadeeep, Bhutta, Zulfiqar A, Biadgo, Belete, Bijani, Ali, Bikbov, Boris, Bililign, Nigus, Bin Sayeed, Muhammad Shahdaat, Birlik, Sait Mentes, Birungi, Charles, Bisanzio, Donal, Biswas, Tuhin, Bjørge, Tone, Bleyer, Archie, Basara, Berrak Bora, Bose, Dipan, Bosetti, Cristina, Boufous, Soufiane, Bourne, Rupert, Brady, Oliver J, Bragazzi, Nicola Luigi, Brant, Luisa C, Brazinova, Alexandra, Breitborde, Nicholas J K, Brenner, Hermann, Britton, Gabrielle, Brugha, Traolach, Burke, Kristin E, Busse, Reinhard, Butt, Zahid A, Cahuana-Hurtado, Lucero, Callender, Charlton S K H, Campos-Nonato, Ismael R, Campuzano Rincon, Julio Cesar, Cano, Jorge, Car, Mate, Cárdenas, Rosario, Carreras, Giulia, Carrero, Juan J, Carter, Austin, Carvalho, Félix, Castañeda-Orjuela, Carlos A, Castillo Rivas, Jacqueline, Castro, Franz, Catalá-López, Ferrán, Çavlin, Alanur, Cerin, Ester, Chaiah, Yazan, Champs, Ana Paula, Chang, Hsing-Yi, Chang, Jung-Chen, Chattopadhyay, Aparajita, Chaturvedi, Pankaj, Chen, Wanqing, Chiang, Peggy Pei-Chia, Chimed-Ochir, Odgerel, Chin, Ken Lee, Chisumpa, Vesper Hichilombwe, Chitheer, Abdulaal, Choi, Jee-Young J, Christensen, Hanne, Christopher, Devasahayam J, Chung, Sheng-Chia, Cicuttini, Flavia M, Ciobanu, Liliana G, Cirillo, Massimo, Claro, Rafael M, Cohen, Aaron J, Collado-Mateo, Daniel, Constantin, Maria-Magdalena, Conti, Sara, Cooper, Cyrus, Cooper, Leslie Trumbull, Cortesi, Paolo Angelo, Cortinovis, Monica, Cousin, Ewerton, Criqui, Michael H, Cromwell, Elizabeth A, Crowe, Christopher Stephen, Crump, John A, Cucu, Alexandra, Cunningham, Matthew, Daba, Alemneh Kabeta, Dachew, Berihun Assefa, Dadi, Abel Fekadu, Dandona, Lalit, Dandona, Rakhi, Dang, Anh Kim, Dargan, Paul I, Daryani, Ahmad, Das, Siddharth K, Das Gupta, Rajat, das Neves, José, Dasa, Tamirat Tesfaye, Dash, Aditya Prasad, Weaver, Nicole Davis, Davitoiu, Dragos Virgil, Davletov, Kairat, Dayama, Anand, Courten, Barbora de, De la Hoz, Fernando Pio, De leo, Diego, De Neve, Jan-Walter, Degefa, Meaza Girma, Degenhardt, Louisa, Degfie, Tizta T, Deiparine, Selina, Dellavalle, Robert P, Demoz, Gebre Teklemariam, Demtsu, Balem Betsu, Denova-Gutiérrez, Edgar, Deribe, Kebede, Dervenis, Nikolaos, Des Jarlais, Don C, Dessie, Getenet Ayalew, Dey, Subhojit, Dharmaratne, Samath Dhamminda, Dhimal, Meghnath, Ding, Eric L, Djalalinia, Shirin, Doku, David Teye, Dolan, Kate A, Donnelly, Christl A, Dorsey, E Ray, Douwes-Schultz, Dirk, Doyle, Kerrie E, Drake, Thomas M, Driscoll, Tim Robert, Dubey, Manisha, Dubljanin, Eleonora, Duken, Eyasu Ejeta, Duncan, Bruce B, Duraes, Andre R, Ebrahimi, Hedyeh, Ebrahimpour, Soheil, Edessa, Dumessa, Edvardsson, David, Eggen, Anne Elise, El Bcheraoui, Charbel, El Sayed Zaki, Maysaa, Elfaramawi, Mohammed, El-Khatib, Ziad, Ellingsen, Christian Lycke, Elyazar, Iqbal R F, Enayati, Ahmadali, Endries, Aman Yesuf Yesuf, Er, Benjamin, Ermakov, Sergey Petrovich, Eshrati, Babak, Eskandarieh, Sharareh, Esmaeili, Reza, Esteghamati, Alireza, Esteghamati, Sadaf, Fakhar, Mahdi, Fakhim, Hamed, Farag, Tamer, Faramarzi, Mahbobeh, Fareed, Mohammad, Farhadi, Farzaneh, Farid, Talha A, Farinha, Carla Sofia e Sá, Farioli, Andrea, Faro, Andre, Farvid, Maryam S, Farzadfar, Farshad, Farzaei, Mohammad Hosein, Fazeli, Mir Sohail, Feigin, Valery L, Feigl, Andrea B, Feizy, Fariba, Fentahun, Netsanet, Fereshtehnejad, Seyed-Mohammad, Fernandes, Eduarda, Fernandes, Joao C, Feyissa, Garumma Tolu, Fijabi, Daniel Obadare, Filip, Irina, Finegold, Samuel, Fischer, Florian, Flor, Luisa Sorio, Foigt, Nataliya A, Ford, John A, Foreman, Kyle J, Fornari, Carla, Frank, Tahvi D, Franklin, Richard Charles, Fukumoto, Takeshi, Fuller, John E, Fullman, Nancy, Fürst, Thomas, Furtado, João M, Futran, Neal D, Galan, Adriana, Gallus, Silvano, Gambashidze, Ketevan, Gamkrelidze, Amiran, Gankpe, Fortune Gbetoho, Garcia-Basteiro, Alberto L, Garcia-Gordillo, Miguel A, Gebre, Teshome, Gebre, Abadi Kahsu, Gebregergs, Gebremedhin Berhe, Gebrehiwot, Tsegaye Tewelde, Gebremedhin, Amanuel Tesfay, Gelano, Tilayie Feto, Gelaw, Yalemzewod Assefa, Geleijnse, Johanna M, Genova-Maleras, Ricard, Gessner, Bradford D, Getachew, Sefonias, Gething, Peter W, Gezae, Kebede Embaye, Ghadami, Mohammad Rasoul, Ghadimi, Reza, Ghasemi Falavarjani, Khalil, Ghasemi-Kasman, Maryam, Ghiasvand, Hesam, Ghimire, Mamata, Ghoshal, Aloke Gopal, Gill, Paramjit Singh, Gill, Tiffany K, Gillum, Richard F, Giussani, Giorgia, Goenka, Shifalika, Goli, Srinivas, Gomez, Ricardo Santiago, Gomez-Cabrera, Mari Carmen, Gómez-Dantés, Hector, Gona, Philimon N, Goodridge, Amador, Gopalani, Sameer Vali, Goto, Atsushi, Goulart, Alessandra C, Goulart, Bárbara Niegia Garcia, Grada, Ayman, Grosso, Giuseppe, Gugnani, Harish Chander, Guimaraes, Andre Luiz Sena, Guo, Yuming, Gupta, Prakash C, Gupta, Rahul, Gupta, Rajeev, Gupta, Tanush, Gyawali, Bishal, Haagsma, Juanita A, Hachinski, Vladimir, Hafezi-Nejad, Nima, Hagos, Tekleberhan B, Hailegiyorgis, Tewodros Tesfa, Hailu, Gessessew Bugssa, Haj-Mirzaian, Arya, Haj-Mirzaian, Arvin, Hamadeh, Randah R, Hamidi, Samer, Handal, Alexis J, Hankey, Graeme J, Harb, Hilda L, Harikrishnan, Sivadasanpillai, Haririan, Hamidreza, Haro, Josep Maria, Hasan, Mehedi, Hassankhani, Hadi, Hassen, Hamid Yimam, Havmoeller, Rasmus, Hay, Roderick J, Hay, Simon I, He, Yihua, Hedayatizadeh-Omran, Akbar, Hegazy, Mohamed I, Heibati, Behzad, Heidari, Mohsen, Hendrie, Delia, Henok, Andualem, Henry, Nathaniel J, Heredia-Pi, Ileana, Herteliu, Claudiu, Heydarpour, Fatemeh, Heydarpour, Pouria, Heydarpour, Sousan, Hibstu, Desalegn Tsegaw, Hoek, Hans W, Hole, Michael K, Homaie Rad, Enayatollah, Hoogar, Praveen, Horino, Masako, Hosgood, H Dean, Hosseini, Seyed Mostafa, Hosseinzadeh, Mehdi, Hostiuc, Sorin, Hostiuc, Mihaela, Hotez, Peter J, Hoy, Damian G, Hsairi, Mohamed, Htet, Aung Soe, Hu, Guoqing, Huang, John J, Husseini, Abdullatif, Hussen, Mohammedaman Mama, Hutfless, Susan, Iburg, Kim Moesgaard, Igumbor, Ehimario U, Ikeda, Chad Thomas, Ilesanmi, Olayinka Stephen, Iqbal, Usman, Irvani, Seyed Sina Naghibi, Isehunwa, Oluwaseyi Oluwakemi, Islam, Sheikh Mohammed Shariful, Islami, Farhad, Jahangiry, Leila, Jahanmehr, Nader, Jain, Rajesh, Jain, Sudhir Kumar, Jakovljevic, Mihajlo, James, Spencer L, Javanbakht, Mehdi, Jayaraman, Sudha, Jayatilleke, Achala Upendra, Jee, Sun Ha, Jeemon, Panniyammakal, Jha, Ravi Prakash, Jha, Vivekanand, Ji, John S, Johnson, Sarah Charlotte, Jonas, Jost B, Joshi, Ankur, Jozwiak, Jacek Jerzy, Jungari, Suresh Banayya, Jürisson, Mikk, K, Madhanraj, Kabir, Zubair, Kadel, Rajendra, Kahsay, Amaha, Kahssay, Molla, Kalani, Rizwan, Kapil, Umesh, Karami, Manoochehr, Karami Matin, Behzad, Karch, André, Karema, Corine, Karimi, Narges, Karimi, Seyed M, Karimi-Sari, Hamidreza, Kasaeian, Amir, Kassa, Getachew Mullu, Kassa, Tesfaye Dessale, Kassa, Zemenu Yohannes, Kassebaum, Nicholas J, Katibeh, Marzieh, Katikireddi, Srinivasa Vittal, Kaul, Anil, Kawakami, Norito, Kazemeini, Hossein, Kazemi, Zhila, Karyani, Ali Kazemi, K C, Prakash, Kebede, Seifu, Keiyoro, Peter Njenga, Kemp, Grant Rodgers, Kengne, Andre Pascal, Keren, Andre, Kereselidze, Maia, Khader, Yousef Saleh, Khafaie, Morteza Abdullatif, Khajavi, Alireza, Khalid, Nauman, Khalil, Ibrahim A, Khan, Ejaz Ahmad, Khan, Gulfaraz, Khan, Muhammad Shahzeb, Khan, Muhammad Ali, Khang, Young-Ho, Khanna, Tripti, Khater, Mona M, Khatony, Alireza, Khazaie, Habibolah, Khoja, Abdullah T, Khosravi, Ardeshir, Khosravi, Mohammad Hossein, Khubchandani, Jagdish, Kiadaliri, Aliasghar A, Kibret, Getiye D Dejenu, Kim, Cho-il, Kim, Daniel, Kim, Jun Y, Kim, Young-Eun, Kimokoti, Ruth W, Kinfu, Yohannes, Kinra, Sanjay, Kisa, Adnan, Kissimova-Skarbek, Katarzyna, Kissoon, Niranjan, Kivimäki, Mika, Kleber, Marcus E, Knibbs, Luke D, Knudsen, Ann Kristin Skrindo, Kochhar, Sonali, Kokubo, Yoshihiro, Kolola, Tufa, Kopec, Jacek A, Kosek, Margaret N, Kosen, Soewarta, Koul, Parvaiz A, Koyanagi, Ai, Kravchenko, Michael A, Krishan, Kewal, Krishnaswami, Sanjay, Kuate Defo, Barthelemy, Kucuk Bicer, Burcu, Kudom, Andreas A, Kuipers, Ernst J, Kulikoff, Xie Rachel, Kumar, G Anil, Kumar, Manasi, Kumar, Pushpendra, Kumsa, Fekede Asefa, Kutz, Michael J, Lad, Sheetal D, Lafranconi, Alessandra, Lal, Dharmesh Kumar, Lalloo, Ratilal, Lam, Hilton, Lami, Faris Hasan, Lan, Qing, Langan, Sinéad M, Lansingh, Van C, Lansky, Sonia, Larson, Heidi Jane, Laryea, Dennis Odai, Lassi, Zohra S, Latifi, Arman, Lavados, Pablo M, Laxmaiah, Avula, Lazarus, Jeffrey V, Lebedev, Georgy, Lee, Paul H, Leigh, James, Leshargie, Cheru Tesema, Leta, Samson, Levi, Miriam, Li, Shanshan, Li, Yichong, Li, Xiaohong, Liang, Juan, Liang, Xiaofeng, Liben, Misgan Legesse, Lim, Lee-Ling, Lim, Stephen S, Limenih, Miteku Andualem, Linn, Shai, Liu, Shiwei, Liu, Yang, Lodha, Rakesh, Logroscino, Giancarlo, Lonsdale, Chris, Lorch, Scott A, Lorkowski, Stefan, Lotufo, Paulo A, Lozano, Rafael, Lucas, Tim C D, Lunevicius, Raimundas, Lyons, Ronan A, Ma, Stefan, Mabika, Crispin, Macarayan, Erlyn Rachelle King, Mackay, Mark T, Maddison, Emilie R, Maddison, Ralph, Madotto, Fabiana, Magdy Abd El Razek, Hassan, Magdy Abd El Razek, Muhammed, Maghavani, Dhaval P, Majdan, Marek, Majdzadeh, Reza, Majeed, Azeem, Malekzadeh, Reza, Malik, Manzoor Ahmad, Malta, Deborah Carvalho, Mamun, Abdullah A, Manamo, Wondimu Ayele, Manda, Ana-Laura, Mansournia, Mohammad Ali, Mantovani, Lorenzo Giovanni, Mapoma, Chabila Christopher, Marami, Dadi, Maravilla, Joemer C, Marcenes, Wagner, Marina, Shakhnazarova, Martinez-Raga, Jose, Martins, Sheila C O, Martins-Melo, Francisco Rogerlândio, März, Winfried, Marzan, Melvin B, Mashamba-Thompson, Tivani Phosa, Masiye, Felix, Massenburg, Benjamin Ballard, Maulik, Pallab K, Mazidi, Mohsen, McGrath, John J, McKee, Martin, Mehata, Suresh, Mehendale, Sanjay Madhav, Mehndiratta, Man Mohan, 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Gabriele Alve, Singam, Narayana Sarma Venkata, Singh, Jasvinder A, Singh, Virendra, Sinha, Anju Pradhan, Sinha, Dhirendra Narain, Sitas, Freddy, Skirbekk, Vegard, Sliwa, Karen, Soares Filho, Adauto Martin, Sobaih, Badr Hasan, Sobhani, Soheila, Soofi, Moslem, Soriano, Joan B, Soyiri, Ireneous N, Sposato, Luciano A, Sreeramareddy, Chandrashekhar T, Srinivasan, Vinay, Srivastava, Rakesh Kumar, Starodubov, Vladimir I, Stathopoulou, Vasiliki, Steel, Nichola, Stein, Dan J, Steiner, Caitlyn, Stewart, Leo G, Stokes, Mark A, Sudaryanto, Agu, Sufiyan, Mu'awiyyah Babale, Sulo, Gerhard, Sunguya, Bruno F, Sur, Patrick John, Sutradhar, Ipsita, Sykes, Bryan L, Sylaja, P.N., Sylte, Dillon O, Szoeke, Cassandra E I, Tabarés-Seisdedos, Rafael, Tabuchi, Takahiro, Tadakamadla, Santosh Kumar, Takahashi, Ken, Tandon, Nikhil, Tassew, Aberash Abay, Tassew, Segen Gebremeskel, Tavakkoli, Mohammad, Taveira, Nuno, Tawye, Nega Yimer, Tehrani-Banihashemi, Arash, Tekalign, Tigist Gashaw, Tekle, Merhawi Gebremedhin, Temesgen, Habtamu, Temsah, Mohamad-Hani, Temsah, Omar, Terkawi, Abdullah Sulieman, Teshale, Manaye Yihune, Tessema, Belay, Teweldemedhin, Mebrahtu, Thakur, Jarnail Singh, Thankappan, Kavumpurathu Raman, Thirunavukkarasu, Sathish, Thomas, Laura Anne, Thomas, Nihal, Thrift, Amanda G, Tilahun, Binyam, To, Quyen G, Tobe-Gai, Ruoyan, Tonelli, Marcello, Topor-Madry, Roman, Topouzis, Foti, Torre, Anna E, Tortajada-Girbés, Miguel, Tovani-Palone, Marcos Roberto, Towbin, Jeffrey A, Tran, Bach Xuan, Tran, Khanh Bao, Tripathi, Suryakant, Tripathy, Srikanth Prasad, Truelsen, Thomas Clement, Truong, Nu Thi, Tsadik, Afewerki Gebremeskel, Tsilimparis, Nikolao, Tudor Car, Lorainne, Tuzcu, E Murat, Tyrovolas, Stefano, Ukwaja, Kingsley Nnanna, Ullah, Irfan, Usman, Muhammad Shariq, Uthman, Olalekan A, Uzun, Selen Begüm, Vaduganathan, Muthiah, Vaezi, Afsane, Vaidya, Gaurang, Valdez, Pascual R, Varavikova, Elena, Varughese, Santosh, Vasankari, Tommi Juhani, Vasconcelos, Ana Maria Nogale, Venketasubramanian, Narayanaswamy, Vidavalur, Ramesh, Villafaina, Santo, Violante, Francesco S, Vladimirov, Sergey Konstantinovitch, Vlassov, Vasily, Vollset, Stein Emil, Vos, Theo, Vosoughi, Kia, Vujcic, Isidora S, Wagner, Gregory R, Wagnew, Fasil Wagnew Shiferaw, Waheed, Yasir, Wang, Yanping, Wang, Yuan-Pang, Wassie, Molla Mesele, Weiderpass, Elisabete, Weintraub, Robert G, Weiss, Daniel J, Weiss, Jordan, Weldegebreal, Fitsum, Weldegwergs, Kidu Gidey, Werdecker, Andrea, Westerman, Ronny, Whiteford, Harvey A, Widecka, Justyna, Widecka, Katarzyna, Wijeratne, Tissa, Winkler, Andrea Sylvia, Wiysonge, Charles Shey, Wolfe, Charles D A, Wondemagegn, Sintayehu Ambachew, Wu, Shouling, Wyper, Grant M A, Xu, Gelin, Yadav, Rajaram, Yakob, Bereket, Yamada, Tomohide, Yan, Lijing L, Yano, Yuichiro, Yaseri, Mehdi, Yasin, Yasin Jemal, Ye, Pengpeng, Yearwood, Jamal A, Yentür, Gökalp Kadri, Yeshaneh, Alex, Yimer, Ebrahim M, Yip, Paul, Yisma, Engida, Yonemoto, Naohiro, Yoon, Seok-Jun, York, Hunter W, Yotebieng, Marcel, Younis, Mustafa Z, Yousefifard, Mahmoud, Yu, Chuanhua, Zachariah, Geevar, Zadnik, Vesna, Zafar, Shamsa, Zaidi, Zoubida, Zaman, Sojib Bin, Zamani, Mohammad, Zare, Zohreh, Zeeb, Hajo, Zeleke, Mulugeta Molla, Zenebe, Zerihun Menlkalew, Zerfu, Taddese Alemu, Zhang, Kai, Zhang, Xueying, Zhou, Maigeng, Zhu, Jun, Zodpey, Sanjay, Zucker, Inbar, Zuhlke, Liesl Joanna J, Lopez, Alan D, Gakidou, Emmanuela, and Murray, Christopher J L

Subjects
Child mortality, Alnæmi, Dánartíðni, Heilsufar, GBD, Börn, Dauði, Almennar lyflækningar, Fullorðnir, General & Internal Medicine, parasitic diseases, Psychology, age-specific mortality, Estimating adult mortality, Medicine (all), HIV, 11 Medical And Health Sciences, General Medicine, All-cause mortality, humanities, Countries, Death, mortality, national, Sálfræði, Health, GBD, mortality, Human medicine, Trends
Abstract

The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders. Data for this research was provided by MEASURE Evaluation, funded by the United States Agency for International Development (USAID). Views expressed do not necessarily reflect those of USAID, the US Government, or MEASURE Evaluation. The Palestinian Central Bureau of Statistics granted the researchers access to relevant data in accordance with licence no. SLN2014-3-170, after subjecting data to processing aiming to preserve the confidentiality of individual data in accordance with the General Statistics Law-2000. The researchers are solely responsible for the conclusions and inferences drawn upon available data., Background Assessments of age-specific mortality and life expectancy have been done by the UN Population Division, Department of Economics and Social Affairs (UNPOP), the United States Census Bureau, WHO, and as part of previous iterations of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD). Previous iterations of the GBD used population estimates from UNPOP, which were not derived in a way that was internally consistent with the estimates of the numbers of deaths in the GBD. The present iteration of the GBD, GBD 2017, improves on previous assessments and provides timely estimates of the mortality experience of populations globally. Methods The GBD uses all available data to produce estimates of mortality rates between 1950 and 2017 for 23 age groups, both sexes, and 918 locations, including 195 countries and territories and subnational locations for 16 countries. Data used include vital registration systems, sample registration systems, household surveys (complete birth histories, summary birth histories, sibling histories), censuses (summary birth histories, household deaths), and Demographic Surveillance Sites. In total, this analysis used 8259 data sources. Estimates of the probability of death between birth and the age of 5 years and between ages 15 and 60 years are generated and then input into a model life table system to produce complete life tables for all locations and years. Fatal discontinuities and mortality due to HIV/AIDS are analysed separately and then incorporated into the estimation. We analyse the relationship between age-specific mortality and development status using the Socio-demographic Index, a composite measure based on fertility under the age of 25 years, education, and income. There are four main methodological improvements in GBD 2017 compared with GBD 2016: 622 additional data sources have been incorporated; new estimates of population, generated by the GBD study, are used; statistical methods used in different components of the analysis have been further standardised and improved; and the analysis has been extended backwards in time by two decades to start in 1950. Findings Globally, 18·7% (95% uncertainty interval 18·4–19·0) of deaths were registered in 1950 and that proportion has been steadily increasing since, with 58·8% (58·2–59·3) of all deaths being registered in 2015. At the global level, between 1950 and 2017, life expectancy increased from 48·1 years (46·5–49·6) to 70·5 years (70·1–70·8) for men and from 52·9 years (51·7–54·0) to 75·6 years (75·3–75·9) for women. Despite this overall progress, there remains substantial variation in life expectancy at birth in 2017, which ranges from 49·1 years (46·5–51·7) for men in the Central African Republic to 87·6 years (86·9–88·1) among women in Singapore. The greatest progress across age groups was for children younger than 5 years; under-5 mortality dropped from 216·0 deaths (196·3–238·1) per 1000 livebirths in 1950 to 38·9 deaths (35·6–42·83) per 1000 livebirths in 2017, with huge reductions across countries. Nevertheless, there were still 5·4 million (5·2–5·6) deaths among children younger than 5 years in the world in 2017. Progress has been less pronounced and more variable for adults, especially for adult males, who had stagnant or increasing mortality rates in several countries. The gap between male and female life expectancy between 1950 and 2017, while relatively stable at the global level, shows distinctive patterns across super-regions and has consistently been the largest in central Europe, eastern Europe, and central Asia, and smallest in south Asia. Performance was also variable across countries and time in observed mortality rates compared with those expected on the basis of development. Interpretation This analysis of age-sex-specific mortality shows that there are remarkably complex patterns in population mortality across countries. The findings of this study highlight global successes, such as the large decline in under-5 mortality, which reflects significant local, national, and global commitment and investment over several decades. However, they also bring attention to mortality patterns that are a cause for concern, particularly among adult men and, to a lesser extent, women, whose mortality rates have stagnated in many countries over the time period of this study, and in some cases are increasing., Research reported in this publication was supported by the Bill & Melinda Gates Foundation, the University of Melbourne, Public Health England, the Norwegian Institute of Public Health, St. Jude Children's Research Hospital, the National Institute on Aging of the National Institutes of Health (award P30AG047845), and the National Institute of Mental Health of the National Institutes of Health (award R01MH110163).

Published
2018

32. Clinical and Radiological Differences between Patients Diagnosed with Acute Ischemic Stroke and Chameleons at the Emergency Room: Insights from a Single-Center Observational Study.

Author

Brunser AM, Lavados PM, Muñoz-Venturelli P, Olavarría VV, Mansilla E, Cavada G, and González PE

Abstract

Introduction: Scarce data exist about clinical/radiological differences between acute ischemic strokes diagnosed in the emergency room (AISER) and stroke chameleons (SCs). We aimed at describing the differences observed in a comprehensive stroke center in Chile., Methods: Prospective observational study of patients with ischemic stroke syndromes admitted to the emergency room (ER) of Clínica Alemana between December 2014 and October 2023., Results: 1,197 patients were included; of these 63 (5.2%, 95% CI: 4.1-6.6) were SC; these were younger (p &lt; 0.001), less frequently hypertensive (p = 0.03), and they also had lower systolic (SBP) (p &lt; 0.001), diastolic blood pressures (DBP) (p = 0.011), and NIHSS (p &lt; 0.001). Clinically, they presented less frequently gaze (p = 0.008) and campimetry alterations (p = 0.03), facial (p &lt; 0.001) and limb weakness (left arm [p = 0.004], right arm (p = 0.041), left leg (p = 0.001), right leg p = 0.0029), sensory abnormalities (p &lt; 0.001), and dysarthria (p &lt; 0.001). Neuroradiological evaluations included less frequently large vessel occlusions (p = 0.01) and other stroke locations (p = 0.005); they also differed in their etiologies (p &lt; 0.001). Brainstem strokes (p &lt; 0.001) and extinction/inattention symptoms (p &lt; 0.001) were only seen in AISER. In multivariate analysis, younger age (OR: 0.945; 95% CI: 0.93-0.96), DBP (OR: 0.97; 95% CI, 0.95-0.99), facial weakness (OR: 0.39; 95% CI: 0.19-0.78), sensory abnormities (OR: 0.16.18; 95% CI, 0.05-0.4), infratentorial location (OR: 0.36; 95% CI, 0.15-0.78), posterior circulation involvement (OR: 3.02; 95% CI, 1.45-6.3), cardioembolic (OR: 3.5; 95% CI, 1.56-7.99), and undetermined (OR: 2.42; 95% CI, 1.22-4.7; 95%) etiologies, remained statistically significant. A stepwise analysis including only clinical elements present on the patient's arrival to the ER, demonstrates that age (OR: 0.95; 95% CI: 0.94-0.97), DBP (OR: 0.97; 95% CI, 0.95-0.99), the presence of atrial fibrillation (OR: 2.22; 95% CI, 1.04-4.75, NIHSS (OR: 0.88; 95% CI, 0.71-0.89) and the presence in NIHSS of 1a level of consciousness (OR: 5.66; CI: 95% 1.8-16.9), 1b level of consciousness questions (OR: 3.023; 95% CI, 1.35-6.8), facial weakness (OR: 0.3; CI: 95% 0.17-0.8), and sensory abnormalities (OR: 0.27; 95% CI, 0.1-0.72) remained statistically significant., Conclusion: SC had clinical and radiological differences compared to AISER. An additional relevant finding is that neurological symptoms in a patient with atrial fibrillation, even with a negative diffusion-weighted imaging, should be carefully evaluated as a potential stroke until other causes are satisfactorily ruled out., (© 2024 S. Karger AG, Basel.)

Published
2024
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33. Intravenous Thrombolysis in Patients 90 Years or Older with Moderate to Severe Acute Ischemic Stroke Increases Ambulation at Discharge and Is Safe: A Prospective Cohort Study from a Single Center in Santiago, Chile.

Author

González PE, Lavados PM, Aguirre AI, Brunser AM, and Olavarría VV

Subjects
Humans, Female, Middle Aged, Aged, Aged, 80 and over, Male, Thrombolytic Therapy adverse effects, Patient Discharge, Chile, Prospective Studies, Treatment Outcome, Intracranial Hemorrhages chemically induced, Intracranial Hemorrhages diagnosis, Walking, Fibrinolytic Agents, Ischemic Stroke diagnosis, Ischemic Stroke drug therapy, Brain Ischemia diagnosis, Brain Ischemia drug therapy, Brain Ischemia complications, Stroke diagnosis, Stroke drug therapy
Abstract

Introduction: The World Health Organization predicts that the global population aged 60 years and older will double by 2050, leading to a significant rise in the public health impact of acute ischemic stroke (AIS). Existing stroke guidelines do not specify an upper age limit for the administration of intravenous thrombolysis (IVT), although some suggest a relative exclusion criterion in patients aged ≥80 in the 3-4.5-h window. Many physicians avoid treating these patients with IVT, argumenting high risk and little benefit. Our aim was to investigate the efficacy and safety of IVT treatment in patients with non-minor AIS aged ≥90, admitted to our institution. The primary efficacy endpoint was the ability to walk at discharge (mRS 0-3), and the primary safety endpoints were death and symptomatic intracranial hemorrhagic transformation (sIHT) at discharge., Methods: Patients with AIS aged ≥90 admitted to our center from January 2003 to December 2022 were included. They were selected if had an NIHSS ≥5, were previously ambulatory (prestroke mRS score 3 or less), and arrived within 6 h from symptom onset. Those treated or not with IVT were compared with univariate analysis., Results: The mean age was 93.2 (2.4) years, and 51 (73.9%) were female. The admission mRS and NIHSS were 1 (IQR 0-2) and 14 (IQR 7-22), respectively. Thrombolyzed patients had a shorter time from symptom onset to door and lower glycemia on admission. IVT was associated with a higher proportion of patients achieving mRS 0-3 at discharge (p = 0.03) and at 90 days (p = 0.04). There were no differences between groups in the risk of death (p = 0.55) or sIHT (p = 0.38)., Conclusion: In this small sample, ambulatory patients aged ≥90 with moderate or severe AIS treated with IVT had increased odds of being able to walk independently at discharge than those not treated, without safety concerns., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Published
2024
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34. Safety and efficacy of factor XIa inhibition with milvexian for secondary stroke prevention (AXIOMATIC-SSP): a phase 2, international, randomised, double-blind, placebo-controlled, dose-finding trial.

Author

Sharma M, Molina CA, Toyoda K, Bereczki D, Bangdiwala SI, Kasner SE, Lutsep HL, Tsivgoulis G, Ntaios G, Czlonkowska A, Shuaib A, Amarenco P, Endres M, Yoon BW, Tanne D, Toni D, Yperzeele L, von Weitzel-Mudersbach P, Sampaio Silva G, Avezum A, Dawson J, Strbian D, Tatlisumak T, Eckstein J, Ameriso SF, Weber JR, Sandset EC, Goar Pogosova N, Lavados PM, Arauz A, Gailani D, Diener HC, Bernstein RA, Cordonnier C, Kahl A, Abelian G, Donovan M, Pachai C, Li D, and Hankey GJ

Subjects
Aged, Female, Humans, Male, Middle Aged, Double-Blind Method, Factor XIa, Hemorrhage chemically induced, Hemorrhage drug therapy, Treatment Outcome, Adult, Brain Ischemia drug therapy, Brain Ischemia prevention & control, Ischemic Attack, Transient drug therapy, Ischemic Stroke drug therapy, Stroke drug therapy, Stroke prevention & control
Abstract

Background: People with factor XI deficiency have lower rates of ischaemic stroke than the general population and infrequent spontaneous bleeding, suggesting that factor XI has a more important role in thrombosis than in haemostasis. Milvexian, an oral small-molecule inhibitor of activated factor XI, added to standard antiplatelet therapy, might reduce the risk of non-cardioembolic ischaemic stroke without increasing the risk of bleeding. We aimed to estimate the dose-response of milvexian for recurrent ischaemic cerebral events and major bleeding in patients with recent ischaemic stroke or transient ischaemic attack (TIA)., Methods: AXIOMATIC-SSP was a phase 2, randomised, double-blind, placebo-controlled, dose-finding trial done at 367 hospitals in 27 countries. Eligible participants aged 40 years or older, with acute (<48 h) ischaemic stroke or high-risk TIA, were randomly assigned by a web-based interactive response system in a 1:1:1:1:1:2 ratio to receive one of five doses of milvexian (25 mg once daily, 25 mg twice daily, 50 mg twice daily, 100 mg twice daily, or 200 mg twice daily) or matching placebo twice daily for 90 days. All participants received clopidogrel 75 mg daily for the first 21 days and aspirin 100 mg daily for the first 90 days. Investigators, site staff, and participants were masked to treatment assignment. The primary efficacy endpoint was the composite of ischaemic stroke or incident covert brain infarct on MRI at 90 days, assessed in all participants allocated to treatment who completed a follow-up MRI brain scan, and the primary analysis assessed the dose-response relationship with Multiple Comparison Procedure-Modelling (MCP-MOD). The main safety outcome was major bleeding at 90 days, assessed in all participants who received at least one dose of the study drug. This trial is registered with ClinicalTrials.gov (NCT03766581) and the EU Clinical Trials Register (2017-005029-19)., Findings: Between Jan 27, 2019, and Dec 24, 2021, 2366 participants were randomly allocated to placebo (n=691); milvexian 25 mg once daily (n=328); or twice-daily doses of milvexian 25 mg (n=318), 50 mg (n=328), 100 mg (n=310), or 200 mg (n=351). The median age of participants was 71 (IQR 62-77) years and 859 (36%) were female. At 90 days, the estimates of the percentage of participants with either symptomatic ischaemic stroke or covert brain infarcts were 16·8 (90·2% CI 14·5-19·1) for placebo, 16·7 (14·8-18·6) for 25 mg milvexian once daily, 16·6 (14·8-18·3) for 25 mg twice daily, 15·6 (13·9-17·5) for 50 mg twice daily, 15·4 (13·4-17·6) for 100 mg twice daily, and 15·3 (12·8-19·7) for 200 mg twice daily. No significant dose-response was observed among the five milvexian doses for the primary composite efficacy outcome. Model-based estimates of the relative risk with milvexian compared with placebo were 0·99 (90·2% CI 0·91-1·05) for 25 mg once daily, 0·99 (0·87-1·11) for 25 mg twice daily, 0·93 (0·78-1·11) for 50 mg twice daily, 0·92 (0·75-1·13) for 100 mg twice daily, and 0·91 (0·72-1·26) for 200 mg twice daily. No apparent dose-response was observed for major bleeding (four [1%] of 682 participants with placebo, two [1%] of 325 with milvexian 25 mg once daily, two [1%] of 313 with 25 mg twice daily, five [2%] of 325 with 50 mg twice daily, five [2%] of 306 with 100 mg twice daily, and five [1%] of 344 with 200 mg twice daily). Five treatment-emergent deaths occurred, four of which were considered unrelated to the study drug by the investigator., Interpretation: Factor XIa inhibition with milvexian, added to dual antiplatelet therapy, did not substantially reduce the composite outcome of symptomatic ischaemic stroke or covert brain infarction and did not meaningfully increase the risk of major bleeding. Findings from our study have informed the design of a phase 3 trial of milvexian for the prevention of ischaemic stroke in patients with acute ischaemic stroke or TIA., Funding: Bristol Myers Squibb and Janssen Research & Development., Competing Interests: Declaration of interests MS has received consulting fees from Janssen, HLS Therapeutics, and Bayer; and has served in a leadership or fiduciary role for the Canadian Stroke Consortium. CAM has received honoraria from Bristol Myers Squibb and Boehringer Ingelheim. KT has received honoraria from Bayer, Daiichi Sankyo, Bristol Myers Squibb, Otsuka, Novartis, and Abbott Medical. DB has received consulting fees from Bristol Myers Squibb, Bayer, Ipsen, and Boehringer Ingelheim; and has received honoraria from Novo Nordisk, HUMAN BioPlazma, and Parexel. SEK has received grants or contracts from Bristol Myers Squibb; and has received consulting fees from Bristol Myers Squibb. HL has received consulting fees from Bristol Myers Squibb; has participated on steering committees or advisory boards for Bristol Myers Squibb, the US National Institute of Neurological Disorders and Stroke, and Coherex Medical; and is on the Editorial Board for Medscape Neurology. GT has received consulting fees from Bristol Myers Squibb. GN has received financial support from Bristol Myers Squibb. AC has participated on a steering committee for Bristol Myers Squibb; has received grants or contracts from Bristol Myers Squibb; and has previously served as the President of the Cerebrovascular Section of Polish Neurological Society, honorary president of the Polish Neurological Society, and in a leadership role for the Angels Initiative— Poland. PA has participated on a steering committee for Bristol Myers Squibb and Janssen; has received grants or contracts from Sanofi, Bristol Myers Squibb, AstraZeneca, Pfizer, Merck, AltheraPharm, and the French Government; has received consulting fees from Bayer, Novartis, and Novo Nordisk; has received honoraria from Viatris and Sanofi; and has participated in an advisory board for Novartis. ME has received grants or contracts from Bayer; has received consulting fees from Bayer; has received honoraria from Abbott, Boehringer Ingelheim, Pfizer, Amgen, GSK, Sanofi, and Novartis; has participated on data safety monitoring boards or advisory boards for Bristol Myers Squibb, Bayer, AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo, Amgen, and Covidien; has served in a leadership or fiduciary role for the European Academy of Neurology, German Neurological Society (DGN), International Society for Cerebral Blood Flow and Metabolism, American Heart Association/American Stroke Association, European Stroke Organisation, World Stroke Organization, German Center for Cardiovascular Research (DZHK), and German Center for Neurodegenerative Diseases (DZNE); and has been a recipient of materials from Amgen. DTa has received consulting fees from QuantaIX Neuroscience, Babylink, and Pi-cardia, and for being a national leader in a randomised controlled trial. DTo has received honoraria from Abbott, Alexion, AstraZeneca, Bayer, Boehringer Ingelheim, Medtronic, and Pfizer. LY has participated in steering committees for Bristol Myers Squibb and Janssen Research & Development; has received honoraria from Bayer, Bristol Myers Squibb, Pfizer, Boehringer Ingelheim, and Daiichi Sankyo; and has received support for attendance at the World Stroke Congress from the World Stroke Organization Future Stroke Leaders Program. PvWM has received contracts and support for attending an investigator meeting from Bristol Myers Squibb; and has served as a national leader and member of a steering committee for Bristol Myers Squibb. GSS has received support from and participated on a steering committee for Bristol Myers Squibb; has received grants or contracts from Boehringer Ingelheim; has received consulting fees from Bristol Myers Squibb and Boehringer Ingelheim; and has participated in an advisory board for Bristol Myers Squibb. AAv has received grants and honoraria from Bayer. JD has received support from Bristol Myers Squibb; has received grants from Pfizer; and has received honoraria from Pfizer, Daiichi Sankyo, and AstraZeneca. DS has received contracts, support for attending a steering committee meeting, and materials and drugs for performing the trial from Bristol Myers Squibb. TT has received grants from the University of Gothenburg, Sahlgrenska University Hospital, and Wennerstrom's Foundation; and has received consulting fees from Bayer, Inventiva Pharma, Bristol Myers Squibb, and Portola Pharmaceuticals. JE has received travel support from Bristol Myers Squibb for attending steering committee meetings. SFA has received grants from Bayer and Boehringer Ingelheim; and has received honoraria from Novo Nordisk and Abbott. JRW has served as President Elect of the Austrian Society of Neurology. ECS has received honoraria from Bristol Myers Squibb, Daiichi Sankyo, and Boston Scientific. NGP has served as the President of the Russian National Society of Preventive Cardiology. PML has received grants from Bristol Myers Squibb and Janssen; has received honoraria from Boehringer Ingelheim and Pfizer; has received support for attending the Global Stroke Alliance; has participated on a data safety monitoring board or advisory board for RapidAI; and has served as the President of the Chilean Stroke Association. DG has received grants or contracts, or both, from the US National Heart, Lung and Blood Institute and the US National Institutes of Health; has received consulting fees from Bristol Myers Squibb, Ionis, Janssen, and Anthos Therapeutics; and has participated on a steering committee for Bristol Myers Squibb. HCD has received support from Bristol Myers Squibb; has received grants from Boehringer Ingelheim and AstraZeneca; has received honoraria from Boehringer Ingelheim, Pfizer, Sanofi, and Bristol Myers Squibb; has received support for attending meetings or travel, or both, from Boehringer Ingelheim; and has participated on data safety monitoring boards or advisory boards for Actelion, the German Research Council, and the ELAN Study. RAB has received consulting fees from and has participated on a steering committee for Bristol Myers Squibb. CC has received honoraria from Bristol Myers Squibb and Amgen; and has participated on data safety monitoring boards or advisory boards for AstraZeneca and Biogen. GA, MD, and CP are employees and shareholders of Bristol Myers Squibb. AK and DL are employees and shareholders of Bristol Myers Squibb; and have a pending patent application related to this study. GJH has received consulting fees from Bristol Myers Squibb, Janssen Research & Development, and Bayer; has received honoraria from Janssen Medical Affairs; has received honoraria for participating on a data safety monitoring board for AC Immune; and has received honoraria from the American Heart Association for serving as an Associate Editor for Circulation. SIB, AS, BWY, and AAr declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Published
2024
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35. Who is in the emergency room matters when we talk about door-to-needle time: a single-center experience.

Author

Brunser AM, Nuñez JC, Mansilla E, Cavada G, Olavarría V, Muñoz Venturelli P, and Lavados PM

Subjects
Humans, Fibrinolytic Agents therapeutic use, Thrombolytic Therapy adverse effects, Thrombolytic Therapy methods, Prospective Studies, Emergency Service, Hospital, Time-to-Treatment, Treatment Outcome, Tissue Plasminogen Activator therapeutic use, COVID-19 complications, Stroke complications, Brain Ischemia complications
Abstract

Background: The efficacy of intravenous thrombolysis (IVT) is time-dependent., Objective: To compare the door-to-needle (DTN) time of stroke neurologists (SNs) versus non-stroke neurologists (NSNs) and emergency room physicians (EPs). Additionally, we aimed to determine elements associated with DTN ≤ 20 minutes., Methods: Prospective study of patients with IVT treated at Clínica Alemana between June 2016 and September 2021., Results: A total of 301 patients underwent treatment for IVT. The mean DTN time was 43.3 ± 23.6 minutes. One hundred seventy-three (57.4%) patients were evaluated by SNs, 122 (40.5%) by NSNs, and 6 (2.1%) by EPs. The mean DTN times were 40.8 ± 23, 46 ± 24.7, and 58 ± 22.5 minutes, respectively. Door-to-needle time ≤ 20 minutes occurred more frequently when patients were treated by SNs compared to NSNs and EPs: 15%, 4%, and 0%, respectively (odds ratio [OR]: 4.3, 95% confidence interval [95%CI]: 1.66-11.5, p  = 0.004). In univariate analysis DTN time ≤ 20 minutes was associated with treatment by a SN ( p  = 0.002), coronavirus disease 2019 pandemic period ( p  = 0.21), time to emergency room (ER) ( p  = 0.21), presence of diabetes ( p  = 0.142), hypercholesterolemia ( p  = 0.007), atrial fibrillation ( p  < 0.09), score on the National Institutes of Health Stroke Scale (NIHSS) ( p  = 0.001), lower systolic ( p  = 0.143) and diastolic ( p  = 0.21) blood pressures, the Alberta Stroke Program Early CT Score (ASPECTS; p  = 0.09), vessel occlusion ( p  = 0.05), use of tenecteplase ( p  = 0.18), thrombectomy ( p  = 0.13), and years of experience of the physician ( p  < 0.001). After multivariate analysis, being treated by a SN (OR: 3.95; 95%CI: 1.44-10.8; p  = 0.007), NIHSS (OR: 1.07; 95%CI: 1.02-1.12; p  < 0.002) and lower systolic blood pressure (OR: 0.98; 95%CI: 0.96-0.99; p  < 0.003) remained significant., Conclusion: Treatment by a SN resulted in a higher probability of treating the patient in a DTN time within 20 minutes., Competing Interests: AMB, VO, PM: reports research grant from Clínica Alemana; JCN, EM, GC: reports no conflicts of interest; PL: reports research grants from The George Institute and Clínica Alemana de Santiago for ENCHANTED, HAEDPOST, and RECCA studies; personal fees from AstraZeneca and Bayer as SOCRATES and ESUS NAVIGATE trials national leader and a Chilean Government research grant for the ÑANDU project outside the submitted., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/).)

Published
2023
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36. Stroke symptoms, risk factors awareness and personal decision making in Chile. A national survey.

Author

Navia V, Mazzon E, Olavarría VV, Almeida J, Brunser AM, Lavados PM, Hoffmeister L, and Muñoz Venturelli P

Subjects
Male, Humans, Female, Middle Aged, Chile epidemiology, Risk Factors, Surveys and Questionnaires, Decision Making, Awareness, Health Knowledge, Attitudes, Practice, Stroke diagnosis, Stroke epidemiology, Stroke therapy
Abstract

Background: Knowledge about stroke symptoms, correct decision in front of a stroke case and recognition of stroke risk factors are crucial to fight against stroke burden. We aimed to assess the stroke awareness among a sample of the Chilean population., Methods: A closed-ended questions structured survey was applied in November 2019 using a computer-assisted telephone interviewing system. Probabilistic sample, random selection and stratification for region was used. Multivariate logistic regression model was used to estimate the association between participants' characteristics and responses., Results: Of 706 participants, only 74.4% (95% CI 70.9-77.5) recognized at least one typical stroke symptom. Most (586, 82.4% 95% CI 75.2-89.7) chose to contact the emergency ambulance or directly go to the emergency department in case of a stroke symptom and recognized at least one risk factor (692, 97.9% CI 96.7-98.8). In multivariable analysis, sociodemographic characteristics associated to a worse recognition of at least one stroke symptom were being men (OR 0.67, 95% CI 0.47-0.96), being 55 years old or older (OR 0.59 95% CI 0.37-0.93) and from the lowest socioeconomic level (SES) (OR 0.33 95% CI 0.16-0.67). Female sex was associated with lower stroke risk factor knowledge (OR 0.64 95% IC 0.47-0.87). Participants who recognized at least one typical stroke symptom and would promptly seek care at an emergency department differed significantly between SES (p=0.001) and age groups (p=0.035)., Conclusions: We found insufficient knowledge about stroke symptoms and best decisions making in the Chilean population. We describe gaps that can be targeted in future stroke awareness campaigns. There is a need to strengthen tailored stroke education particularly for underserved populations., Competing Interests: Declarations of interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Published
2022
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37. Did COVID-19 impact stroke services? A multicenter study.

Author

Shokri H, Nahas NE, Basiony AE, Nguyen TN, Abdalkader M, Klein P, Lavados PM, Olavarría VV, Amaya P, Llanos-Leyton N, Brola W, Michał L, Fariña DEDM, Cardozo A, Caballero CD, Pedrozo F, Rahman A, Hokmabadi ES, Jalili J, Farhoudi M, Aref H, and Roushdy T

Subjects
Cross-Sectional Studies, Humans, Retrospective Studies, Thrombolytic Therapy, Time-to-Treatment, Treatment Outcome, COVID-19, Stroke drug therapy, Stroke therapy
Abstract

Background: It has been reported that acute stroke services were compromised during COVID-19 due to various pandemic-related issues. We aimed to investigate these changes by recruiting centers from different countries., Methods: Eight countries participated in this cross-sectional, observational, retrospective study by providing data from their stroke data base. We compared 1 year before to 1 year during COVID-19 as regards onset to door (OTD), door to needle (DTN), door to groin (DTG), duration of hospital stay, National Institute of Health Stroke Scale (NIHSS) at baseline, 24 h, and at discharge as well as modified Rankin score (mRS) on discharge and at 3 months follow-up., Results: During the pandemic year, there was a reduction in the number of patients, median age was significantly lower, admission NIHSS was higher, hemorrhagic stroke increased, and OTD and DTG showed no difference, while DTN time was longer, rtPA administration was decreased, thrombectomy was more frequent, and hospital stay was shorter. mRS was less favorable on discharge and at 3 months., Conclusion: COVID-19 showed variable effects on stroke services. Some were negatively impacted as the number of patients presenting to hospitals, DTN time, and stroke outcome, while others were marginally affected as the type of management., (© 2022. The Author(s).)

Published
2022
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38. Temporal Trends of Intravenous Thrombolysis Utilization in Acute Ischemic Stroke in a Prospective Cohort From 1998 to 2019: Modeling Based on Joinpoint Regression.

Author

Olavarría VV, Hoffmeister L, Vidal C, Brunser AM, Hoppe A, and Lavados PM

Abstract

Introduction: The frequency of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is lower than it should be in several regions of the world. It is unclear what interventions can produce significant improvements in IVT utilization. We aimed to investigate the temporal trends in IVT in AIS and identify changes in time that could be associated with specific interventions., Methods: We included patients with AIS who were admitted from January 1998 to December 2019 in our institution. To analyze trends in utilization and time points in which they changed, we performed a Joinpoint regression analysis. Interventions were assigned to a specific category according to the Behavior Change Wheel framework intervention function criteria., Results: A total of 3,361 patients with AIS were admitted, among which 538 (16%) received IVT. There were 245 (45.5%) women, and the mean age and median National Institutes of Health Stroke Scale (NIHSS) scores were 68.5 (17.2) years and 8 (interquartile range, 4-15), respectively. Thrombolysis use significantly increased by an average annual 7.6% (95% CI, 5.1-10.2), with one Joinpoint in 2007. The annual percent changes were.45% from 1998 to 2007 and 9.57% from 2007 to 2019, concurring with the stroke code organization, the definition of door-to-needle times as an institutional performance measure quality indicator, and the extension of the therapeutic window., Conclusions: The IVT rates consistently increased due to a continuous process of protocol changes and multiple interventions. The implementation of a complex multidisciplinary intervention such as the stroke code, as well as the definition of a hospital quality control metric, were associated with a significant change in this trend., Competing Interests: VO reports receiving research grants from Clínica Alemana de Santiago, Boehringer-Ingelheim, and ANID. PL reports research support from Clínica Alemana de Santiago and Boehringer Ingelheim, research grants from The George Institute and Clínica Alemana de Santiago during the conduct of the study, unrestricted research grants from Lundbeck and Boehringer Ingelheim, personal fees from AstraZeneca and Bayer as SOCRATES and ESUS NAVIGATE trials national leader, and a Chilean Government research grant for the ÑANDU project outside the submitted work. AB received a research grant from Clínica Alemana de Santiago for the RECCA registry. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Olavarría, Hoffmeister, Vidal, Brunser, Hoppe and Lavados.)

Published
2022
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39. Diffusion-weighted imaging as predictor of acute ischemic stroke etiology.

Author

Brunser AM, Mansilla E, Navia V, Mazzon E, Rojo A, Cavada G, Olavarría V, Venturelli PM, and Lavados PM

Subjects
Diffusion Magnetic Resonance Imaging, Humans, Atherosclerosis, Ischemic Stroke, Stroke diagnostic imaging, Stroke etiology, Stroke pathology
Abstract

Background: Topographic patterns may correlate with causes of ischemic stroke., Objective: To investigate the association between diffusion-weighted imaging (DWI) and Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification., Methods: We included 1019 ischemic stroke patients. DWI were classified as: i) negative; ii) DWI single lesion (cortico-subcortical, cortical, subcortical ≥20 mm, or subcortical <20 mm); iii) scattered lesions in one territory (small scattered lesions or confluent with additional lesions); and iv) multiple lesions (multiple unilateral anterior circulation [MAC], multiple posterior circulation [MPC], multiple bilateral anterior circulation [MBAC], and multiple anterior and posterior circulations [MAP])., Results: There was a relationship between DWI patterns and TOAST classification (p<0.001). Large artery atherosclerosis was associated with small, scattered lesions in one vascular territory (Odds Ratio [OR] 4.22, 95% confidence interval [95%CI] 2.61-6.8), MPC (OR 3.52; 95%CI 1.54-8.03), and subcortical lesions <20 mm (OR 3.47; 95%CI 1.76-6.85). Cardioembolic strokes correlated with MAP (OR 4.3; 95%CI 1.64-11.2), cortico-subcortical lesions (OR 3.24; 95%CI 1.9-5.5) and negative DWI (OR 2.46; 95%CI 1.1-5.49). Cryptogenic strokes correlated with negative DWI (OR 4.1; 95%CI 1,84-8.69), cortical strokes (OR 3.3; 95%CI 1.25-8.8), MAP (OR 3.33; 95%CI 1.25-8.81) and subcortical lesion ≥20 mm (OR 2.44; 95%CI 1,04-5.73). Lacunar strokes correlated with subcortical lesions diameter <20 mm (OR 42.9; 95%CI 22.7-81.1) and negative DWI (OR 8.87; 95%CI 4.03-19.5). Finally, MBAC (OR 9.25; 95%CI 1.12-76.2), MAP (OR 5.54; 95%CI 1.94-15.1), and MPC (OR 3.61; 95%CI 1.5-8.7) correlated with stroke of other etiologies., Conclusions: A relationship exists between DWI and stroke subtype.

Published
2022
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40. Associations of Early Systolic Blood Pressure Control and Outcome After Thrombolysis-Eligible Acute Ischemic Stroke: Results From the ENCHANTED Study.

Author

Wang X, Minhas JS, Moullaali TJ, Di Tanna GL, Lindley RI, Chen X, Arima H, Chen G, Delcourt C, Bath PM, Broderick JP, Demchuk AM, Donnan GA, Durham AC, Lavados PM, Lee TH, Levi C, Martins SO, Olavarria VV, Pandian JD, Parsons MW, Pontes-Neto OM, Ricci S, Sato S, Sharma VK, Silva F, Thang NH, Wang JG, Woodward M, Chalmers J, Song L, Anderson CS, and Robinson TG

Subjects
Aged, Aged, 80 and over, Humans, Intracranial Hemorrhages chemically induced, Intracranial Hemorrhages prevention & control, Middle Aged, Prospective Studies, Tissue Plasminogen Activator adverse effects, Blood Pressure, Hypertension complications, Hypertension physiopathology, Hypertension therapy, Ischemic Stroke etiology, Ischemic Stroke physiopathology, Ischemic Stroke therapy, Thrombolytic Therapy, Tissue Plasminogen Activator administration & dosage
Abstract

Background and Purpose: In thrombolysis-eligible patients with acute ischemic stroke, there is uncertainty over the most appropriate systolic blood pressure (SBP) lowering profile that provides an optimal balance of potential benefit (functional recovery) and harm (intracranial hemorrhage). We aimed to determine relationships of SBP parameters and outcomes in thrombolyzed acute ischemic stroke patients., Methods: Post hoc analyzes of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study), a partial-factorial trial of thrombolysis-eligible and treated acute ischemic stroke patients with high SBP (150-180 mm Hg) assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) alteplase and intensive (target SBP, 130-140 mm Hg) or guideline-recommended (target SBP <180 mm Hg) treatment. All patients were followed up for functional status and serious adverse events to 90 days. Logistic regression models were used to analyze 3 SBP summary measures postrandomization: attained (mean), variability (SD) in 1-24 hours, and magnitude of reduction in 1 hour. The primary outcome was a favorable shift on the modified Rankin Scale. The key safety outcome was any intracranial hemorrhage., Results: Among 4511 included participants (mean age 67 years, 38% female, 65% Asian) lower attained SBP and smaller SBP variability were associated with favorable shift on the modified Rankin Scale (per 10 mm Hg increase: odds ratio, 0.76 [95% CI, 0.71-0.82]; P <0.001 and 0.86 [95% CI, 0.76-0.98]; P =0.025) respectively, but not for magnitude of SBP reduction (0.98, [0.93-1.04]; P =0.564). Odds of intracranial hemorrhage was associated with higher attained SBP and greater SBP variability (1.18 [1.06-1.31]; P =0.002 and 1.34 [1.11-1.62]; P =0.002) but not with magnitude of SBP reduction (1.05 [0.98-1.14]; P =0.184)., Conclusions: Attaining early and consistent low levels in SBP <140 mm Hg, even as low as 110 to 120 mm Hg, over 24 hours is associated with better outcomes in thrombolyzed acute ischemic stroke patients. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01422616.

Published
2022
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41. Risk Factors and Diet Components Determining Adherence to the Mediterranean Diet in Acute Ischemic Stroke Patients: A Cross-Sectional Analysis of a Prospective Hospital Register Study.

Author

Olavarría VV, Navia VH, Mazzon E, Rojo A, Brunser AM, and Lavados PM

Subjects
Aged, Aged, 80 and over, Cross-Sectional Studies, Female, Hospitals, Humans, Male, Middle Aged, Prospective Studies, Registries, Risk Factors, Diet, Mediterranean, Ischemic Stroke diet therapy, Treatment Adherence and Compliance statistics & numerical data
Abstract

Objectives: Low adherence to a Mediterranean diet (MeDi) is associated with increased incidence, mortality, and severity of acute ischemic strokes (AIS). Nevertheless, the explanatory factors associated with such results are unclear. Our aim was to investigate stroke risk factors associated with adherence to a MeDi in a prospective cohort of AIS patients., Materials and Methods: Patients admitted from February 2017 to February 2020 were included in this study. Adherence was measured using the 14-point Mediterranean Diet Adherence Screener (MEDAS). Demographic and clinical characteristics were compared with adherence with a univariate analysis. A binomial regression was used to investigate the independent association of premorbid factors and MeDi components with adherence., Results: There were 413 patients. Mean age was 68.6 (17.4), 176 (42.6%) women. Median MEDAS score was 6 (IQR 4-7) points. 253 patients (61.2%) had a low adherence (MEDAS ≤ 6). In the univariate analysis, a low MEDAS was associated with lower education, diabetes, sedentary lifestyle, greater body mass index (BMI), lower alcohol consumption, and higher LDLc. In the regression analysis, younger age, lower education, functional disability, hypertension, sedentary lifestyle, and higher BMI were associated with lower MEDAS scores. Six MeDi components had particularly low patient adherence: seafood, legumes, olive oil, nuts, wine, and fruit., Discussion: These data indicate low adherence to MeDi in younger patients who are less educated and have existing cardiovascular risk factors, in particular hypertension, sedentary lifestyle, and higher BMI. Some components of the diet had a particularly low adherence., Conclusions: Tailoring diet prevention interventions to these specific populations, focusing on components with known less adherence, could improve adherence to a MeDi and the opportunity for secondary stroke prevention., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Published
2022
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42. Decline in subarachnoid haemorrhage volumes associated with the first wave of the COVID-19 pandemic.

Author

Nguyen TN, Haussen DC, Qureshi MM, Yamagami H, Fujinaka T, Mansour OY, Abdalkader M, Frankel M, Qiu Z, Taylor A, Lylyk P, Eker OF, Mechtouff L, Piotin M, Lima FO, Mont'Alverne F, Izzath W, Sakai N, Mohammaden M, Al-Bayati AR, Renieri L, Mangiafico S, Ozretic D, Chalumeau V, Ahmad S, Rashid U, Hussain SI, John S, Griffin E, Thornton J, Fiorot JA, Rivera R, Hammami N, Cervantes-Arslanian AM, Dasenbrock HH, Vu HL, Nguyen VQ, Hetts S, Bourcier R, Guile R, Walker M, Sharma M, Frei D, Jabbour P, Herial N, Al-Mufti F, Ozdemir AO, Aykac O, Gandhi D, Chugh C, Matouk C, Lavoie P, Edgell R, Beer-Furlan A, Chen M, Killer-Oberpfalzer M, Pereira VM, Nicholson P, Huded V, Ohara N, Watanabe D, Shin DH, Magalhaes PS, Kikano R, Ortega-Gutierrez S, Farooqui M, Abou-Hamden A, Amano T, Yamamoto R, Weeks A, Cora EA, Sivan-Hoffmann R, Crosa R, Möhlenbruch M, Nagel S, Al-Jehani H, Sheth SA, Lopez Rivera VS, Siegler JE, Sani AF, Puri AS, Kuhn AL, Bernava G, Machi P, Abud DG, Pontes-Neto OM, Wakhloo AK, Voetsch B, Raz E, Yaghi S, Mehta BP, Kimura N, Murakami M, Lee JS, Hong JM, Fahed R, Walker G, Hagashi E, Cordina SM, Roh HG, Wong K, Arenillas JF, Martinez-Galdamez M, Blasco J, Rodriguez Vasquez A, Fonseca L, Silva ML, Wu TY, John S, Brehm A, Psychogios M, Mack WJ, Tenser M, Todaka T, Fujimura M, Novakovic R, Deguchi J, Sugiura Y, Tokimura H, Khatri R, Kelly M, Peeling L, Murayama Y, Winters HS, Wong J, Teleb M, Payne J, Fukuda H, Miyake K, Shimbo J, Sugimura Y, Uno M, Takenobu Y, Matsumaru Y, Yamada S, Kono R, Kanamaru T, Morimoto M, Iida J, Saini V, Yavagal D, Bushnaq S, Huang W, Linfante I, Kirmani J, Liebeskind DS, Szeder V, Shah R, Devlin TG, Birnbaum L, Luo J, Churojana A, Masoud HE, Lopez CY, Steinfort B, Ma A, Hassan AE, Al Hashmi A, McDermott M, Mokin M, Chebl A, Kargiotis O, Tsivgoulis G, Morris JG, Eskey CJ, Thon J, Rebello L, Altschul D, Cornett O, Singh V, Pandian J, Kulkarni A, Lavados PM, Olavarria VV, Todo K, Yamamoto Y, Silva GS, Geyik S, Johann J, Multani S, Kaliaev A, Sonoda K, Hashimoto H, Alhazzani A, Chung DY, Mayer SA, Fifi JT, Hill MD, Zhang H, Yuan Z, Shang X, Castonguay AC, Gupta R, Jovin TG, Raymond J, Zaidat OO, and Nogueira RG

Subjects
Cross-Sectional Studies, Humans, Pandemics, Prospective Studies, Retrospective Studies, SARS-CoV-2, Treatment Outcome, COVID-19, Intracranial Aneurysm diagnostic imaging, Intracranial Aneurysm epidemiology, Intracranial Aneurysm therapy, Subarachnoid Hemorrhage diagnostic imaging, Subarachnoid Hemorrhage epidemiology
Abstract

Background: During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study's objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines., Methods: We conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March-31 May 2020. The prior 1-year control period (1 March-31 May 2019) was obtained to account for seasonal variation., Findings: There was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI -24.3% to -20.7%, p<0.0001). Embolisation of ruptured aneurysms declined with 1170-1035 procedures, respectively, representing an 11.5% (95%CI -13.5% to -9.8%, p=0.002) relative drop. Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations, a 24.9% relative decline (95% CI -28.0% to -22.1%, p<0.0001). A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1% (95% CI 32.3% to 50.6%, p=0.008) despite a decrease in SAH admissions in this tertile., Interpretation: There was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction., Competing Interests: Competing interests: TNN: PI CLEAR study (Medtronic). DCH: Stryker, Vesalio, Cerenovus consultant. AEH: consultant and speaker for Medtronic, Stryker, Microvention, Penumbra, Balt, Scientia, Genentech and GE Healthcare. PJ: Medtronic, Microvention, Balt, Cerenovus consultant. SO-G: Medtronic, Stryker consultant. DSL: Cerenovus, Genentech, Stryker, Medtronic consultant. TGJ: advisor/investor for Anaconda, Route92, FreeOx, and Blockade Medical; Medtronic grants, DAWN, AURORA PI (Stryker). WJM: consultant: Rebound Therapeutics, Viseon Imperative Care, Q’Apel, Stryker, Stream Biomedical, Spartan Micro; Investor: Cerebrotech, Endostream, Q’Apel, Viseon, Rebound, and Spartan Micro. RGN: Stryker; Cerenovus/Neuravi; Anaconda, Cerebrotech, Ceretrieve, Vesalio (Advisory Board); Imperative Care., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Published
2021
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43. COVID-19 Lockdown Effects on Acute Stroke Care in Latin America.

Author

Pujol-Lereis VA, Flores A, Barboza MA, Abanto-Argomedo C, Amaya P, Bayona H, Bonardo P, Diaz-Escobar L, Gomez-Schneider M, Góngora-Rivera F, Lavados PM, Leon C, Luraschi A, Marquez-Romero JM, Ouriques-Martins SC, Navia VH, Ruiz-Franco A, Vences MÁ, Zurrú MC, Arauz A, and Ameriso SF

Subjects
COVID-19 transmission, Cause of Death trends, Endovascular Procedures adverse effects, Endovascular Procedures mortality, Female, Health Care Surveys, Hospital Mortality trends, Humans, Latin America, Length of Stay trends, Male, Patient Admission trends, Patient Discharge trends, Stroke diagnosis, Stroke mortality, Time Factors, Treatment Outcome, COVID-19 prevention & control, Endovascular Procedures trends, Hospitalization trends, Practice Patterns, Physicians' trends, Stroke therapy, Time-to-Treatment trends
Abstract

Objectives: COVID-19 pandemic has forced important changes in health care worldwide. Stroke care networks have been affected, especially during peak periods. We assessed the impact of the pandemic and lockdowns in stroke admissions and care in Latin America., Materials and Methods: A multinational study (7 countries, 18 centers) of patients admitted during the pandemic outbreak (March-June 2020). Comparisons were made with the same period in 2019. Numbers of cases, stroke etiology and severity, acute care and hospitalization outcomes were assessed., Results: Most countries reported mild decreases in stroke admissions compared to the same period of 2019 (1187 vs. 1166, p = 0.03). Among stroke subtypes, there was a reduction in ischemic strokes (IS) admissions (78.3% vs. 73.9%, p = 0.01) compared with 2019, especially in IS with NIHSS 0-5 (50.1% vs. 44.9%, p = 0.03). A substantial increase in the proportion of stroke admissions beyond 48 h from symptoms onset was observed (13.8% vs. 20.5%, p < 0.001). Nevertheless, no differences in total reperfusion treatment rates were observed, with similar door-to-needle, door-to-CT, and door-to-groin times in both periods. Other stroke outcomes, as all-type mortality during hospitalization (4.9% vs. 9.7%, p < 0.001), length of stay (IQR 1-5 days vs. 0-9 days, p < 0.001), and likelihood to be discharged home (91.6% vs. 83.0%, p < 0.001), were compromised during COVID-19 lockdown period., Conclusions: In this Latin America survey, there was a mild decrease in admissions of IS during the COVID-19 lockdown period, with a significant delay in time to consultations and worse hospitalization outcomes., Competing Interests: Declarations of Competing Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Published
2021
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44. Smoking influences outcome in patients who had thrombolysed ischaemic stroke: the ENCHANTED study.

Author

Sun L, Song L, Yang J, Lindley RI, Robinson T, Lavados PM, Delcourt C, Arima H, Ovbiagele B, Chalmers J, Anderson CS, and Wang X

Subjects
Female, Fibrinolytic Agents, Humans, Male, Smoking adverse effects, Treatment Outcome, Brain Ischemia diagnosis, Brain Ischemia drug therapy, Ischemic Stroke diagnosis, Ischemic Stroke drug therapy, Stroke diagnosis, Stroke drug therapy
Abstract

Background and Purpose: As studies vary in defining the prognostic significance of smoking in acute ischaemic stroke (AIS), we aimed to determine the relation of smoking and key outcomes in patient participants who had thrombolysed AIS of the international quasi-factorial randomised Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED)., Methods: Post-hoc analyses of ENCHANTED, an international quasi-factorial randomised evaluation of intravenous alteplase-dose comparison and levels of blood pressure control in patients who had thrombolysed AIS. Multivariable logistic regression models with inverse probability of treatment weighting (IPTW) propensity scores were used to determine associations of self-reported smoking status and clinical outcomes, according to 90-day modified Rankin Scale (mRS) scores and symptomatic intracerebral haemorrhage (sICH)., Results: Of 4540 patients who had an AIS, there were 1008 (22.2%) current smokers who were younger and predominantly male, with more comorbidities of hypertension, coronary artery disease, atrial fibrillation and diabetes mellitus, and greater baseline neurological impairment, compared with non-smokers. In univariate analysis, current smokers had a higher likelihood of a favourable shift in mRS scores (OR 0.88, 95% CI 0.77 to 0.99; p=0.038) but this association reversed in a fully adjusted model with IPTW (adjusted OR 1.15, 95% CI 1.04 to 1.28; p=0.009). A similar trend was also apparent for dichotomised poor outcome (mRS scores 2-6: OR 1.18, 95% CI 1.05 to 1.33; p=0.007), but not with the risk of sICH across standard criteria., Conclusion: Smoking predicts poor functional recovery in patients who had thrombolysed AIS., Trial Registration Number: NCT01422616., Competing Interests: Competing interests: RTL reports personal fees from Covidien and Pfizer; HA reports lecture fees from Takeda, Daiichi Sankyo, Astellas, and Aska Pharmaceuticals; outside the submitted work; JC reports research grants and lecture fees from Servier for the ADVANCE trial and post-trial follow-up; BO reports receiving fees for service on the data and safety monitoring committee of the THALES (ticagrelor) trial. CA reports personal lecture fees and travel support, and grants paid to his institution, from Takeda China., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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2021
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45. In-Hospital Acute Ischemic Stroke is Associated with Worse Outcome: Experience of a Single Center in Santiago Chile.

Author

Brunser A, Navia V V, Araneda P, Mazzon E, Muñoz P, Cavada G, Olavarría VV, and Lavados PM

Subjects
Aged, Aged, 80 and over, Chile, Comorbidity, Female, Hospital Mortality, Humans, Ischemic Stroke diagnostic imaging, Ischemic Stroke mortality, Male, Middle Aged, Neuroimaging, Registries, Retrospective Studies, Risk Assessment, Risk Factors, Time Factors, Time-to-Treatment, Treatment Outcome, Healthcare Disparities, Hospitalization, Inpatients, Ischemic Stroke therapy, Thrombolytic Therapy adverse effects, Thrombolytic Therapy mortality
Abstract

Objectives: In-hospital acute ischemic stroke (HIS) accounts for 2-17% of all acute ischemic strokes (AIS) seen in hospital and they have worse prognosis. In this study we aimed to identify the frequency of HIS and their characteristics in our center., Materials and Methods: Retrospective analysis of a prospective register of patients with AIS seen at Clínica Alemana de Santiago, between January 2017 and January 2019. HIS and community onset ischemic strokes patients (CIS) were compared, univariate analysis was performed, covariates with p < 0.25 were selected for multivariate analysis. Differences between, proportion of strokes treated with thrombolytic therapy, door to needle time were compared between HIS and CIS patients, as also mortality rates at 90 days., Results: During the study period 369 patients with AIS were seen; of these 20 (5.4%, 95 CI%, 3.5-8.2) corresponded to HIS. In univariate analysis, HIS compared to patients arriving form the community to the emergency room, suffered more frequently from, heart failure (p = 0.04), and active malignancies (p < 0.001). HIS patients had longer times from symptom onset to non-contrast brain tomography (540 ±150 minutes); they were also less frequently treated with intravenous thrombolysis compared to community AIS: 15% versus 30% respectively (p = 0.08). Mortality rates at 90 days were higher in HIS: 30 versus 5% (p = 0.001)., Conclusions: In this cohort, HIS patients suffered delays in their neuroimaging studies and received less intravenous thrombolysis; this underscores the need for a standardized approach to the recognition and management of inhospital acute ischemic stroke., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Published
2021
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46. Oxygen desaturation and adverse outcomes in acute stroke: Secondary analysis of the HeadPoST study.

Author

Ouyang M, Roffe C, Billot L, Song L, Wang X, Muñoz-Venturelli P, Lavados PM, Robinson T, Middleton S, Olavarría VV, Watkins CL, Lee TH, Brunser AM, Pontes-Neto OM, Hackett ML, and Anderson CS

Subjects
Adult, Aged, Cross-Over Studies, Female, Humans, Male, Middle Aged, Oxygen Saturation, Patient Positioning, Recovery of Function, Stroke
Abstract

Objective: Uncertainty exists over the prognostic significance of low arterial oxygen saturation (SaO 2 ) in acute stroke. We aimed to determine the strength of association of SaO 2 and adverse outcomes among participants of the international Head Positioning in acute Stroke Trial (HeadPoST)., Methods: Post-hoc analyzes of HeadPoST, a pragmatic cluster-crossover randomized trial of lying flat versus sitting up head positioning in 11,093 patients (age ≥18 years) with acute stroke at 114 hospitals in 9 countries during 2015-2016. Associations of the lowest recorded SaO 2 level, as a continuous measure and as a cut-point for desaturation (SaO 2 <93%), in the first 24 h and clinical outcomes of death or dependency (modified Rankin scale [mRS] scores 3-6) and any serious adverse event (SAE) at 90 days, were assessed in generalized linear mixed models adjusted for baseline and in-hospital management confounders., Results: There was an inverse J-shaped association between SaO 2 and death or dependency, with a nadir for optimal outcome at 96-97%. Patients with SaO 2 desaturation were older, and had greater neurological impairment, premorbid disability and cardiorespiratory disease. Desaturation was not clearly associated with death or dependency (adjusted odds ratio [aOR] 1.19, 95% confidence interval [CI] 0.95-1.48) but was with SAEs (aOR 1.34, 95% CI 1.07-1.68), without heterogeneity by head position, cardiac-respiratory comorbidity, or other pre-specified subgroups., Conclusions: Any change in SaO 2 outside of 96-97% is associated with poorer outcome after acute stroke., Clinical Trial Registration: HeadPoST is registered at ClinicalTrials.gov (NCT02162017)., (Copyright © 2021 Elsevier B.V. All rights reserved.)

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2021
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47. Global impact of COVID-19 on stroke care.

Author

Nogueira RG, Abdalkader M, Qureshi MM, Frankel MR, Mansour OY, Yamagami H, Qiu Z, Farhoudi M, Siegler JE, Yaghi S, Raz E, Sakai N, Ohara N, Piotin M, Mechtouff L, Eker O, Chalumeau V, Kleinig TJ, Pop R, Liu J, Winters HS, Shang X, Vasquez AR, Blasco J, Arenillas JF, Martinez-Galdamez M, Brehm A, Psychogios MN, Lylyk P, Haussen DC, Al-Bayati AR, Mohammaden MH, Fonseca L, Luís Silva M, Montalverne F, Renieri L, Mangiafico S, Fischer U, Gralla J, Frei D, Chugh C, Mehta BP, Nagel S, Mohlenbruch M, Ortega-Gutierrez S, Farooqui M, Hassan AE, Taylor A, Lapergue B, Consoli A, Campbell BC, Sharma M, Walker M, Van Horn N, Fiehler J, Nguyen HT, Nguyen QT, Watanabe D, Zhang H, Le HV, Nguyen VQ, Shah R, Devlin T, Khandelwal P, Linfante I, Izzath W, Lavados PM, Olavarría VV, Sampaio Silva G, de Carvalho Sousa AV, Kirmani J, Bendszus M, Amano T, Yamamoto R, Doijiri R, Tokuda N, Yamada T, Terasaki T, Yazawa Y, Morris JG, Griffin E, Thornton J, Lavoie P, Matouk C, Hill MD, Demchuk AM, Killer-Oberpfalzer M, Nahab F, Altschul D, Ramos-Pachón A, Pérez de la Ossa N, Kikano R, Boisseau W, Walker G, Cordina SM, Puri A, Luisa Kuhn A, Gandhi D, Ramakrishnan P, Novakovic-White R, Chebl A, Kargiotis O, Czap A, Zha A, Masoud HE, Lopez C, Ozretic D, Al-Mufti F, Zie W, Duan Z, Yuan Z, Huang W, Hao Y, Luo J, Kalousek V, Bourcier R, Guile R, Hetts S, Al-Jehani HM, AlHazzani A, Sadeghi-Hokmabadi E, Teleb M, Payne J, Lee JS, Hong JM, Sohn SI, Hwang YH, Shin DH, Roh HG, Edgell R, Khatri R, Smith A, Malik A, Liebeskind D, Herial N, Jabbour P, Magalhaes P, Ozdemir AO, Aykac O, Uwatoko T, Dembo T, Shimizu H, Sugiura Y, Miyashita F, Fukuda H, Miyake K, Shimbo J, Sugimura Y, Beer-Furlan A, Joshi K, Catanese L, Abud DG, Neto OG, Mehrpour M, Al Hashmi A, Saqqur M, Mostafa A, Fifi JT, Hussain S, John S, Gupta R, Sivan-Hoffmann R, Reznik A, Sani AF, Geyik S, Akıl E, Churojana A, Ghoreishi A, Saadatnia M, Sharifipour E, Ma A, Faulder K, Wu T, Leung L, Malek A, Voetsch B, Wakhloo A, Rivera R, Barrientos Iman DM, Pikula A, Lioutas VA, Thomalla G, Birnbaum L, Machi P, Bernava G, McDermott M, Kleindorfer D, Wong K, Patterson MS, Fiorot JA Jr, Huded V, Mack W, Tenser M, Eskey C, Multani S, Kelly M, Janardhan V, Cornett O, Singh V, Murayama Y, Mokin M, Yang P, Zhang X, Yin C, Han H, Peng Y, Chen W, Crosa R, Frudit ME, Pandian JD, Kulkarni A, Yagita Y, Takenobu Y, Matsumaru Y, Yamada S, Kono R, Kanamaru T, Yamazaki H, Sakaguchi M, Todo K, Yamamoto N, Sonoda K, Yoshida T, Hashimoto H, Nakahara I, Cora E, Volders D, Ducroux C, Shoamanesh A, Ospel J, Kaliaev A, Ahmed S, Rashid U, Rebello LC, Pereira VM, Fahed R, Chen M, Sheth SA, Palaiodimou L, Tsivgoulis G, Chandra R, Koyfman F, Leung T, Khosravani H, Dharmadhikari S, Frisullo G, Calabresi P, Tsiskaridze A, Lobjanidze N, Grigoryan M, Czlonkowska A, de Sousa DA, Demeestere J, Liang C, Sangha N, Lutsep HL, Ayo-Martín Ó, Cruz-Culebras A, Tran AD, Young CY, Cordonnier C, Caparros F, De Lecinana MA, Fuentes B, Yavagal D, Jovin T, Spelle L, Moret J, Khatri P, Zaidat O, Raymond J, Martins S, and Nguyen T

Subjects
Cross-Sectional Studies, Hospitals, High-Volume trends, Hospitals, Low-Volume trends, Humans, Intracranial Hemorrhages diagnosis, Intracranial Hemorrhages epidemiology, Registries, Retrospective Studies, Stroke diagnosis, Stroke epidemiology, Time Factors, COVID-19, Global Health, Hospitalization trends, Intracranial Hemorrhages therapy, Stroke therapy, Thrombectomy trends
Abstract

Background: The COVID-19 pandemic led to profound changes in the organization of health care systems worldwide., Aims: We sought to measure the global impact of the COVID-19 pandemic on the volumes for mechanical thrombectomy, stroke, and intracranial hemorrhage hospitalizations over a three-month period at the height of the pandemic (1 March-31 May 2020) compared with two control three-month periods (immediately preceding and one year prior)., Methods: Retrospective, observational, international study, across 6 continents, 40 countries, and 187 comprehensive stroke centers. The diagnoses were identified by their ICD-10 codes and/or classifications in stroke databases at participating centers., Results: The hospitalization volumes for any stroke, intracranial hemorrhage, and mechanical thrombectomy were 26,699, 4002, and 5191 in the three months immediately before versus 21,576, 3540, and 4533 during the first three pandemic months, representing declines of 19.2% (95%CI, -19.7 to -18.7), 11.5% (95%CI, -12.6 to -10.6), and 12.7% (95%CI, -13.6 to -11.8), respectively. The decreases were noted across centers with high, mid, and low COVID-19 hospitalization burden, and also across high, mid, and low volume stroke/mechanical thrombectomy centers. High-volume COVID-19 centers (-20.5%) had greater declines in mechanical thrombectomy volumes than mid- (-10.1%) and low-volume (-8.7%) centers (p < 0.0001). There was a 1.5% stroke rate across 54,366 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.9% (784/20,250) of all stroke admissions., Conclusion: The COVID-19 pandemic was associated with a global decline in the volume of overall stroke hospitalizations, mechanical thrombectomy procedures, and intracranial hemorrhage admission volumes. Despite geographic variations, these volume reductions were observed regardless of COVID-19 hospitalization burden and pre-pandemic stroke/mechanical thrombectomy volumes.

Published
2021
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48. Effects of an Avocado-based Mediterranean Diet on Serum Lipids for Secondary Prevention after Ischemic Stroke Trial (ADD-SPISE): Study protocol.

Author

Olavarría VV, Campodónico P, Vollrath V, von Geldern P, Velásquez C, Pavez P, Valente B, Donoso P, Ginesta A, Cavada G, Mazzon E, Navia V, Guzmán M, Brinck P, and Lavados PM

Subjects
Diet, Fat-Restricted, Humans, Ischemic Stroke blood, Prospective Studies, Randomized Controlled Trials as Topic, Cholesterol, LDL blood, Diet, Mediterranean, Ischemic Stroke prevention & control, Persea, Secondary Prevention
Abstract

Competing Interests: PC, VV, PvG, CV, PP, BV, PD, AG, GC, EM, MG, and PB report no conflicts of interest.

Published
2021
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49. Incidence, risk factors, prognosis, and health-related quality of life after stroke in a low-resource community in Chile (ÑANDU): a prospective population-based study.

Author

Lavados PM, Hoffmeister L, Moraga AM, Vejar A, Vidal C, Gajardo C, Portales B, San Martín D, Lopez E, Rojo A, Olavarria VV, Almeida J, Brunser AM, Muñoz Venturelli P, Diaz V, Hoppe A, and Sacks C

Subjects
Adult, Aged, Aged, 80 and over, Chile epidemiology, Female, Hemorrhagic Stroke epidemiology, Humans, Incidence, Ischemic Stroke epidemiology, Male, Middle Aged, Poverty, Prevalence, Prognosis, Prospective Studies, Racial Groups, Risk Factors, Stroke mortality, Time Factors, Young Adult, Quality of Life, Stroke epidemiology
Abstract

Background: Stroke is a leading cause of disability and death worldwide. The best estimates of local, national, and global burden of stroke are derived from prospective population-based studies. We aimed to investigate the incidence, risk factors, long-term prognosis, care, and quality of life after stroke in the Ñuble region of Chile., Methods: We did a prospective community-based study with use of multiple overlapping sources of hospitalised, ambulatory, and deceased cases. Standardised diagnostic criteria were used to identify and follow up all cases occurring in the resident population of the Ñuble region, Chile (in a low-income rural-urban population including predominantly people of Indigenous-European heritage), for 1 year. Participants were included if they had a clinical diagnosis of stroke confirmed according to the study criteria. All cases were adjudicated by vascular neurologists. Incidence rates of first-ever stroke were calculated from the population of Ñuble according to the 2017 national census., Findings: From April 1, 2015, to March 31, 2016, we ascertained 1103 stroke cases, of which 890 (80·7%) were first-ever incident cases. The mean age of patients with first-ever stroke was 70·3 years (SD 14·1) and 443 (49·8%) were women. A CT scan was obtained in 801 (90%) of 890 patients (mean time from symptom onset to scan of 13·4 h (SD 29·8). The incidence of first-ever stroke age-adjusted to the world population was 121·7 (95% CI 113·7-130·1) per 100 000. The age-adjusted incidence rates, per 100 000 inhabitants, by main pathological subtypes were as follows: ischaemic stroke (101·5 [95% CI 90·9-113·0]); intracerebral haemorrhage (17·9 [13·5-23·4]), and subarachnoid haemorrhage (4·2 [2·1-7·3]). The 30-day case-fatality rate was 24·6% (21·9-27·6). At 6 months after the stroke, 55·9% (432 of 773) of cases had died or were disabled, which increased to 61·0% (456 of 747) at 12 months. Health-related quality of life in survivors was low at 6 months, improving slightly at 12 months after the stroke., Interpretation: The incidence of stroke in this low-resource population was higher than our previous finding in northern Chile and within the mid-range of most population-based stroke studies. This result was due mainly to a higher incidence of ischaemic stroke, probably associated with increasing age and a high prevalence of cardiometabolic risk factors in the population studied. Our findings suggest that more should be done for the prevention and care of stroke in communities like the Ñuble population., Funding: The National Agency for Research and Development and the Technology-Health Research Fund, Clínica Alemana de Santiago, Boehringer Ingelheim, Bristol Meyers Squibb, The Herminda Martin Clinical Hospital of Chillán, Universidad Mayor, and Universidad de Concepción., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Published
2021
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50. Validation of the simplified modified Rankin scale for stroke trials: Experience from the ENCHANTED alteplase-dose arm.

Author

Chen X, Li J, Anderson CS, Lindley RI, Hackett ML, Robinson T, Lavados PM, Wang X, Arima H, Chalmers J, and Delcourt C

Subjects
Humans, Quality of Life, Reproducibility of Results, Tissue Plasminogen Activator therapeutic use, Treatment Outcome, Brain Ischemia drug therapy, Stroke drug therapy
Abstract

Background and Aims: The structured, simplified modified Rankin scale questionnaire (smRSq) may increase reliability over the interrogative approach to scoring the modified Rankin scale (mRS) in acute stroke research and practice. During the conduct of the alteplase-dose arm of the international ENhanced Control of Hypertension ANd Thrombolysis StrokE stuDy (ENCHANTED), we had an opportunity to compare each of these approaches to outcome measurement., Methods: Baseline demographic data were recorded together with the National Institutes of Health Stroke Scale (NIHSS). Follow-up measures obtained at 90 days included mRS, smRSq, and the 5-Dimension European Quality of life scale (EQ-5D). Agreements between smRSq and mRS were assessed with the Kappa statistic. Multiple logistic regression was used to identify baseline predictors of Day 90 smRSq and mRS scores. Treatment effects, based on Day 90 smRSq/mRS scores, were tested in logistic and ordinal logistic regression models., Results: SmRSq and mRS scores had good agreement (weighted Kappa 0.79, 95% confidence interval (CI) 0.78-0.81), while variables of age, atrial fibrillation, diabetes mellitus, pre-morbid mRS (1 vs. 0), baseline NIHSS scores, and imaging signs of cerebral ischemia, similarly predicted their scores. Odds ratios for death or disability, and ordinal shift, 90-day mRS scores using smRSq were 1.05 (95% CI 0.91-1.20; one-sided P = 0.23 for non-inferiority) and 0.98 (95% CI 0.87-1.11; P = 0.02 for non-inferiority), similar to those using mRS., Conclusions: This study demonstrates the utility of the smRSq in a large, ethnically diverse clinical trial population. Scoring of the smRSq shows adequate agreement with the standard mRS, thus confirming it is a reliable, valid, and useful alternative measure of functional status after acute ischemic stroke., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01422616.

Published
2021
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