Stroke; a journal of cerebral circulation
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Meta Analysis
Optimal Duration of Aspirin Plus Clopidogrel After Ischemic Stroke or Transient Ischemic Attack.
Background and Purpose- The role of aspirin plus clopidogrel (A+C) therapy compared with aspirin monotherapy in patients presenting with acute ischemic stroke (IS) or transient ischemic attack remains uncertain. We conducted this study to determine the optimal period of efficacy and safety of A+C compared with aspirin monotherapy. Methods- Ten randomized controlled trials (15 434 patients) were selected using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) (inception June 2018) comparing A+C with aspirin monotherapy in patients with transient ischemic attack or IS. ⋯ Intermediate-term (RR, 2.58; 95% CI, 1.19-5.60) and long-term (RR, 1.87; 95% CI, 1.36-2.56) A+C regimens significantly increased the risk of major bleeding as opposed to short-term A+C (RR, 1.82; 95% CI, 0.91-3.62). Excessive all-cause mortality was limited to long-term A+C (RR, 1.45; 95% CI, 1.10-1.93). Conclusions- Short-term A+C is more effective and equally safe in comparison to aspirin alone in patients with acute IS or transient ischemic attack.
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Background and Purpose- We used a decision analysis approach to analyze triage strategies for patients with acute stroke symptoms while accounting for prehospital large vessel occlusion (LVO) screening methods and key time metrics. Methods- Our decision analysis compared anticipated functional outcomes for patients within the IV-tPA (intravenous tissue-type plasminogen activator) treatment window in the mothership and drip-and-ship frameworks. Key branches of the model included IV-tPA eligibility, presence of an LVO, and endovascular therapy eligibility. ⋯ For example, mothership was favored with an additional transport time to the comprehensive stroke center of <32 to 99 minutes for patients screened positive for an LVO and <28 to 39 minutes in the absence of screening. Conclusions- Joint consideration of LVO probability, screening, workflow times, and transport times may improve prehospital stroke triage. Drip-and-ship was more favorable when more ideal primary stroke center workflow times were modeled.
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Comparative Study
Comparative Effectiveness of Endovascular Thrombectomy in Elderly Stroke Patients.
Background and Purpose- Strokes in patients aged ≥80 years are common, and advanced age is associated with relatively poor poststroke functional outcome. The current guidelines do not recommend an upper age limit for endovascular thrombectomy (EVT). The purpose of this study is to evaluate the effectiveness of EVT in acute stroke because of large vessel occlusion for elderly patients >age 80 years. ⋯ Conclusions- Our study demonstrates the impact of relevant factors on the effectiveness of EVT in patients above 80 years of age. Morbidity and mortality after both IVT and EVT strategies significantly influence the outcomes in both healthy and disabled patients at baseline. Better identification of patients not benefiting from IVT would optimize the selective use of EVT thereby improving its effectiveness.
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Background and Purpose- Emergency medical services (EMSs) are critical for early treatment of patients with ischemic stroke, yet data on EMS utilization and its association with timely treatment in China are still limited. Methods- We examined data from the Chinese Stroke Center Alliance for patients with ischemic stroke from June 2015 to June 2018. Absolute standardized difference was used for covariates' balance assessments. ⋯ Compared with self-transport, EMS transport was associated with significantly shorter onset-to-door time, door-to-needle time (if prenotification was sent), earlier arrival (adjusted odds ratio [95% CIs] were 2.07 [1.95-2.20] for onset-to-door time ≤2 hours, 2.32 [2.18-2.47] for onset-to-door time ≤3.5 hours), and more rapid treatment (2.96 [2.88-3.05] for IV-tPA [intravenous recombinant tissue-type plasminogen activator] in eligible patients, 1.70 [1.62-1.77] for treatment with IV-tPA by 3 hours if onset-to-door time ≤2 hours, and 1.76 [1.70-1.83] for treatment with IV-tPA by 4.5 hours if onset-to-door time ≤3.5 hours). Conclusions- Although EMS transportation is associated with substantial reductions in prehospital delay and improved likelihood of early arrival and timely treatment, rate of utilization is currently low among Chinese patients with ischemic stroke. Developing an efficient EMS system and promoting culture-adapted education efforts are necessary for improving EMS activation.
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Background and Purpose- Evidence on the effects of coarse particulate matter (PM10-2.5) on ischemic stroke is limited and inconsistent. We evaluated the acute effects of PM10-2.5 exposure on hospital admissions for ischemic stroke in China. Methods- We conducted a national time-series analysis of associations between daily PM10-2.5 concentrations and daily hospital admissions for ischemic stroke in China between January 2014 and December 2016. ⋯ The exposure-response relationship was approximately linear, with a moderate response at lower levels (<200 μg/m3) and a steeper response at higher levels. The association was stronger in cities with lower PM10-2.5 concentrations, higher temperatures, or higher relative humidity. Conclusions- This nationwide study provides robust evidence of the short-term association between exposure to PM10-2.5 and increased hospital admissions for ischemic stroke and supports the hypothesis that the association differs by city characteristics.