BACKGROUND: Insight in differences in patient outcomes between endovascular thrombectomy (EVT) centers can help to improve stroke care. We assessed between-center variation in functional outcome of patients with acute ischemic stroke who were treated with EVT. We analyzed to what extent this variation may be explained by modifiable center characteristics. METHODS: We used nationwide registry data of patients with stroke treated with EVT in the Netherlands and in the Czech Republic. Primary outcome was modified Rankin Scale score at 90 days as an indicator of disability. We used multilevel ordinal logistic regression to quantify the between-center variation in outcomes and the impact of patient and center characteristics. Between-center variation was expressed as the relative difference in odds of a more favorable modified Rankin Scale score between a relatively better performing center (75th percentile) and a relatively worse performing center (25th percentile). RESULTS: We included a total of 4518 patients treated in 33 centers. Adjusted for patient characteristics, the odds of a more favorable outcome in a center at the 75th percentile of the outcome distribution were 1.46 times higher (95% CI, 1.31-1.70) than the odds in a center at the 25th percentile. Adjustment for center characteristics, including the median time between stroke onset and reperfusion per center, decreased this relative difference in odds to 1.30 (95% CI, 1.18-1.50, P=0.01). This translates into an absolute difference in likelihood of good functional outcome of 8% after adjustment for patient characteristics and to 5% after further adjustment for modifiable center characteristics. CONCLUSIONS: The considerable between-center variation in patient outcomes after EVT for acute ischemic stroke could be largely explained by center-specific characteristics, such as time to reperfusion. Improvement of these parameters may likely result in a decrease in center-specific differences, and an overall improvement in outcome of patients with acute ischemic stroke.
- MeSH
- cévní mozková příhoda * diagnóza etiologie terapie MeSH
- endovaskulární výkony * škodlivé účinky MeSH
- ischemická cévní mozková příhoda * MeSH
- ischemie mozku * diagnóza etiologie terapie MeSH
- lidé MeSH
- registrace MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
BACKGROUND: Chronic cerebrospinal venous insufficiency (CCSVI) has recently been introduced as a chronic state of impaired cerebral or cervical venous drainage that may be causally implicated in multiple sclerosis (MS) pathogenesis. Moreover, percutaneous transluminal angioplasty of extracranial veins termed "Liberation treatment" has been proposed (based on nonrandomized data) as an alternative therapy for MS. METHODS: A comprehensive literature search was conducted to identify available published, peer-reviewed, clinical studies evaluating (1) the association of CCSVI with MS, (2) the reproducibility of proposed ultrasound criteria for CCSVI detection (3) the safety and efficacy of "Liberation treatment" in open-label and randomized-controlled trial (RCT) settings. RESULTS: There is substantial heterogeneity between ultrasound case-control studies investigating the association of CCSVI and MS. The majority of independent investigators failed to reproduce the initially reported high prevalence rates of CCSVI in MS. The prevalence of extracranial venous stenoses evaluated by other neuroimaging modalities (contrast or MR venography) is similarly low in MS patients and healthy individuals. One small RCT failed to document any benefit in MS patients with CCSVI receiving "Liberation treatment", while an exacerbation of disease activity was observed. "Liberation treatment" has been complicated by serious adverse events (SAEs) in open-label studies (e.g., stroke, internal jugular vein thrombosis, stent migration, hydrocephalus). CONCLUSION: CCSVI appears to be a poorly reproducible and clinically irrelevant sonographic construct. "Liberation treatment" has no proven efficacy, may exacerbate underlying disease activity and has been complicated with SAEs. "Liberation treatment" should stop being offered to MS patients even in the settings of RCTs.
- MeSH
- angioplastika * MeSH
- chronická nemoc MeSH
- lidé MeSH
- randomizované kontrolované studie jako téma MeSH
- reprodukovatelnost výsledků MeSH
- roztroušená skleróza komplikace MeSH
- výsledek terapie MeSH
- žilní insuficience komplikace terapie ultrasonografie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- přehledy MeSH
BACKGROUND: There are limited data regarding the use of intravenous thrombolysis in patients who experienced acute ischemic symptoms during their hospitalization for prior transient ischemic attack. AIM: We sought to prospectively evaluate the safety and efficacy of intravenous thrombolysis for the treatment of acute ischemic stroke occurring during hospitalization for transient ischemic attack in an international, multicenter study. METHODS: Consecutive patients with acute ischemic stroke that occurred during hospitalization for prior transient ischemic attack were treated with intravenous thrombolysis in five tertiary-care stroke centers. Early arterial recanalization was determined by transcranial Doppler at the end of recombinant tissue plasminogen activator infusion using previously validated criteria. Symptomatic intracranial hemorrhage complicating intravenous thrombolysis was evaluated using the National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study definition. Functional independence at three-months was defined as Modified Rankin Scale score of 0-2. RESULTS: Systemic recombinant tissue plasminogen activator infusion (median onset-to-treatment time 70 mins, interquartile range 50-150) was given in 25 consecutive patients (mean age 66 ± 10 years) who developed acute ischemic stroke symptoms (median National Institutes of Health Stroke Scale score 10 points; interquartile range 8-14) during hospitalization for prior transient ischemic attack (median ABCD(2) score 5 points; median time-to-symptom recurrence 24 h, interquartile range 24-48). No symptomatic intracranial hemorrhage (0%; 95% confidence interval 0-12%) was documented. Early complete recanalization occurred in 64% of patients (95% confidence interval 44-80%), and 84% (95% confidence interval 65-94%) achieved three-month functional independence. The rate of three-month functional independence was higher in patients treated with intravenous tissue plasminogen activator within 90 mins from symptom onset compared with those with onset-to-treatment time>90 mins (81% vs. 33%; P = 0.031). CONCLUSIONS: Intravenous thrombolysis for symptoms of acute ischemic stroke occurring after hospitalization for transient ischemic attack appears to be safe. These pilot data support resetting the clock if new symptoms recur shortly after transient ischemic attack.
- MeSH
- časové faktory MeSH
- cévní mozková příhoda terapie MeSH
- fibrinolytika aplikace a dávkování MeSH
- hospitalizace statistika a číselné údaje MeSH
- intravenózní podání MeSH
- krvácení etiologie MeSH
- lidé středního věku MeSH
- lidé MeSH
- mezinárodní spolupráce MeSH
- neparametrická statistika MeSH
- neurozobrazování MeSH
- prospektivní studie MeSH
- senioři MeSH
- tkáňový aktivátor plazminogenu aplikace a dávkování MeSH
- tranzitorní ischemická ataka komplikace MeSH
- ultrasonografie dopplerovská transkraniální MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- práce podpořená grantem MeSH
BACKGROUND AND PURPOSE: Intraventricular hemorrhage is associated with high mortality and poor functional outcome. The use of intraventricular fibrinolytic (IVF) therapy as an intervention in intraventricular hemorrhage is an evolving therapy with conflicting reports in the literature. The goal of this study is to investigate the impact of IVF on mortality, functional outcome, ventriculitis, shunt dependence, and rehemorrhage. METHODS: During March and April 2014, a systematic literature search was performed identifying 1359 articles. Of these, 24 met inclusion criteria. A random effects meta-analysis was performed using both pooled and subset analysis based on study type. RESULTS: Our meta-analysis demonstrated that IVF reduced mortality in intraventricular hemorrhage by nearly half (relative risk [RR], 0.55; 95% confidence interval [CI], 0.42-0.71; P<0.00001), increased the likelihood of good functional outcome by 66% (RR, 1.66; 95% CI, 1.27-2.19; P=0.0003), and also decreased the rate of shunt dependence (RR, 0.62; 95% CI, 0.42-0.93; P=0.02). IVF was not found to be associated with increased rates of ventriculitis (RR=1.46; 95% CI, 0.77-2.76; P=0.25) or rehemorrhage (RR=1.06; 95% CI, 0.66-1.70; P=0.80). We detected no evidence of publication bias. CONCLUSIONS: Our meta-analysis showed that IVF is safe and could be an effective strategy for the treatment of intraventricular hemorrhage. It may reduce mortality, improve functional outcome, and diminish the need for permanent ventricular shunting, while not increasing the risk of ventriculitis or rehemorrhage.
