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  • 1
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    Etiologic subtypes of first and recurrent ischemic stroke in young patients using A-S-C-O and TOAST classification criteria: A retrospective follow-up study
    SAGE Publications ; 2024
    In:  European Stroke Journal
    Details
    In: European Stroke Journal, SAGE Publications
    Abstract: Scarce data exist on the etiology of recurrent ischemic strokes (ISs) among young adults. We analyzed the etiology of first-ever and recurrent events and the differences between them. Patients and methods: Patients aged 15–49 years with a first-ever IS in 1994–2007 were included in the Helsinki Young Stroke Registry. In this retrospective cohort study, data on recurrent ISs were identified from Care Register for Health Care until the end of 2017 and Causes of Death Register and from patient records until the end of 2020. All first-ever and recurrent ISs were classified using Atherosclerosis-Small vessel disease-Cardioembolism-Other Cause (A-S-C-O) and Trial of Org 10172 in Acute Stroke Treatment (TOAST) classifications. Results: A total of 970 patients were included (median age at index IS 46 years, interquartile range 43–48, 33% women), of which 155 (16.0%) patients had recurrent IS, with 8 (5.2%) fatal cases and 5 (3.2%) unverifiable cases. The median follow-up was 17.4 (IQR 13.9–21.7) years. Median time from the index event to the first recurrent event was 4.5 (interquartile range [IQR] 1.6–10.2) years. Recurrence was more often due to definite cardioembolism (10.7% vs 18.0%, p = 0.013), while the proportion of other definite A-S-C-O subgroups remained the same. With TOAST classification, the proportion of true cryptogenic ISs decreased (16.7% vs 6.7%, p = 0.003), while those with incomplete evaluation increased (9.3% vs 19.3%, p = 0.015). Other TOAST phenotypes remained the same. Conclusion: The proportion of definite cardioembolism increased at recurrence using the A-S-C-O classification and the number of cryptogenic ISs decreased using the TOAST classification, while cases with incomplete evaluation increased. Most etiologies remained the same.
    Type of Medium: Online Resource
    ISSN: 2396-9873 , 2396-9881
    URL: Article
    DOI: 10.1177/23969873241238508
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2024
    detail.hit.zdb_id: 2851287-X
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  • 2
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    Rivaroxaban for secondary stroke prevention in patients with embolic strokes of undetermined source: Design of the NAVIGATE ESUS randomized trial
    SAGE Publications ; 2016
    In:  European Stroke Journal Vol. 1, No. 3 ( 2016-09), p. 146-154
    Details
    In: European Stroke Journal, SAGE Publications, Vol. 1, No. 3 ( 2016-09), p. 146-154
    Abstract: Embolic strokes of undetermined source comprise up to 20% of ischemic strokes. The stroke recurrence rate is substantial with aspirin, widely used for secondary prevention. The New Approach riVaroxaban Inhibition of Factor Xa in a Global trial versus ASA to prevenT Embolism in Embolic Stroke of Undetermined Source international trial will compare the efficacy and safety of rivaroxaban, an oral factor Xa inhibitor, versus aspirin for secondary prevention in patients with recent embolic strokes of undetermined source. Main hypothesis In patients with recent embolic strokes of undetermined source, rivaroxaban 15 mg once daily will reduce the risk of recurrent stroke (both ischemic and hemorrhagic) and systemic embolism (primary efficacy outcome) compared with aspirin 100 mg once daily. Design Double-blind, randomized trial in patients with embolic strokes of undetermined source, defined as nonlacunar cryptogenic ischemic stroke, enrolled between seven days and six months from the qualifying stroke. The planned sample size of 7000 participants will be recruited from approximately 480 sites in 31 countries between 2014 and 2017 and followed for a mean of about two years until at least 450 primary efficacy outcome events have occurred. The primary safety outcome is major bleeding. Two substudies assess (1) the relative effect of treatments on MRI-determined covert brain infarcts and (2) the biological underpinnings of embolic strokes of undetermined source using genomic and biomarker approaches. Summary The New Approach riVaroxaban Inhibition of Factor Xa in a Global trial versus ASA to prevenT Embolism in Embolic Stroke of Undetermined Source trial is evaluating the benefits and risks of rivaroxaban for secondary stroke prevention in embolic strokes of undetermined source patients. Main results are anticipated in 2018.
    Type of Medium: Online Resource
    ISSN: 2396-9873 , 2396-9881
    URL: Article
    DOI: 10.1177/2396987316663049
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2016
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  • 3
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    Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Triggers, Causes, and Outcome (SECRETO): Rationale and design
    SAGE Publications ; 2017
    In:  European Stroke Journal Vol. 2, No. 2 ( 2017-06), p. 116-125
    Details
    In: European Stroke Journal, SAGE Publications, Vol. 2, No. 2 ( 2017-06), p. 116-125
    Abstract: Worldwide, about 1.3 million annual ischaemic strokes (IS) occur in adults aged 〈 50 years. Of these early-onset strokes, up to 50% can be regarded as cryptogenic or associated with conditions with poorly documented causality like patent foramen ovale and coagulopathies. Key hypotheses/aims (1) Investigate transient triggers and clinical/sub-clinical chronic risk factors associated with cryptogenic IS in the young; (2) use cardiac imaging methods exceeding state-of-the-art to reveal novel sources for embolism; (3) search for covert thrombosis and haemostasis abnormalities; (4) discover new disease pathways using next-generation sequencing and RNA gene expression studies; (5) determine patient prognosis by use of phenotypic and genetic data; and (6) adapt systems medicine approach to investigate complex risk-factor interactions. Design Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome (SECRETO; NCT01934725) is a prospective multi-centre case–control study enrolling patients aged 18–49 years hospitalised due to first-ever imaging-proven IS of undetermined etiology. Patients are examined according to a standardised protocol and followed up for 10 years. Patients are 1:1 age- and sex-matched to stroke-free controls. Key study elements include centralised reading of echocardiography, electrocardiography, and neurovascular imaging, as well as blood samples for genetic, gene-expression, thrombosis and haemostasis and biomarker analysis. We aim to have 600 patient–control pairs enrolled by the end of 2018. Summary SECRETO is aiming to establish novel mechanisms and prognosis of cryptogenic IS in the young and will provide new directions for therapy development for these patients. First results are anticipated in 2019.
    Type of Medium: Online Resource
    ISSN: 2396-9873 , 2396-9881
    URL: Article
    DOI: 10.1177/2396987317703210
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2017
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  • 4
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    Early recurrence in paroxysmal versus sustained atrial fibrillation in patients with acute ischaemic stroke
    SAGE Publications ; 2019
    In:  European Stroke Journal Vol. 4, No. 1 ( 2019-03), p. 55-64
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    In: European Stroke Journal, SAGE Publications, Vol. 4, No. 1 ( 2019-03), p. 55-64
    Abstract: The relationship between different patterns of atrial fibrillation and early recurrence after an acute ischaemic stroke is unclear. Purpose In a prospective cohort study, we evaluated the rates of early ischaemic recurrence after an acute ischaemic stroke in patients with paroxysmal atrial fibrillation or sustained atrial fibrillation which included persistent and permanent atrial fibrillation. Methods In patients with acute ischaemic stroke, atrial fibrillation was categorised as paroxysmal atrial fibrillation or sustained atrial fibrillation. Ischaemic recurrences were the composite of ischaemic stroke, transient ischaemic attack and symptomatic systemic embolism occurring within 90 days from acute index stroke. Results A total of 2150 patients (1155 females, 53.7%) were enrolled: 930 (43.3%) had paroxysmal atrial fibrillation and 1220 (56.7%) sustained atrial fibrillation. During the 90-day follow-up, 111 ischaemic recurrences were observed in 107 patients: 31 in patients with paroxysmal atrial fibrillation (3.3%) and 76 with sustained atrial fibrillation (6.2%) (hazard ratio (HR) 1.86 (95% CI 1.24–2.81)). Patients with sustained atrial fibrillation were on average older, more likely to have diabetes mellitus, hypertension, history of stroke/ transient ischaemic attack, congestive heart failure, atrial enlargement, high baseline NIHSS-score and implanted pacemaker. After adjustment by Cox proportional hazard model, sustained atrial fibrillation was not associated with early ischaemic recurrences (adjusted HR 1.23 (95% CI 0.74–2.04)). Conclusions After acute ischaemic stroke, patients with sustained atrial fibrillation had a higher rate of early ischaemic recurrence than patients with paroxysmal atrial fibrillation. After adjustment for relevant risk factors, sustained atrial fibrillation was not associated with a significantly higher risk of recurrence, thus suggesting that the risk profile associated with atrial fibrillation, rather than its pattern, is determinant for recurrence.
    Type of Medium: Online Resource
    ISSN: 2396-9873 , 2396-9881
    URL: Article
    DOI: 10.1177/2396987318785853
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2019
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  • 5
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    Leucocyte Count in Young Adults with First-Ever Ischaemic Stroke: Associated Factors and Association on Prognosis
    SAGE Publications ; 2015
    In:  International Journal of Stroke Vol. 10, No. 2 ( 2015-02), p. 245-250
    Details
    In: International Journal of Stroke, SAGE Publications, Vol. 10, No. 2 ( 2015-02), p. 245-250
    Abstract: Limited data exist on the associated factors and correlation of leucocyte count to outcome in young adults with first-ever ischaemic stroke. Aims Our objectives were to investigate factors associated with elevated leucocyte count and whether there is correlation between leucocyte count and short- and long-term outcomes. Methods Of our database of 1008 consecutive patients aged 15 to 49, we included those with leucocyte count measured within the first two days from stroke onset. Outcomes were three-month and long-term disability, death, and vascular events. Linear regression was used to explore baseline variables associated with leucocyte count. Logistic regression and Cox proportional models studied the association between leucocyte count and clinical outcomes. Results In our study cohort of 781 patients (61·7% males; mean age 41·4 years), mean leucocyte count was high: 8·8 ± 3·1 × 10 9 cells/L (Reference range: 3·4–8·2 × 10 9 cells/L). Higher leucocyte levels were associated with dyslipidaemia, smoking, peripheral arterial disease, stroke severity, and lesion size. After adjustment for age, gender, relevant risk factors, both continuous leucocyte count and the highest quartile of leucocyte count were independently associated with unfavourable three-month outcome. Regarding events in the long-term (follow-up 8·1 ± 4·2 years in survivors), no association between leucocyte count and the event risks appeared. Conclusions Among young stroke patients, high leucocyte count was a common finding. It was associated with vascular disease and its risk factors as well as severity of stroke, but it was also independently associated with unfavourable three-month outcome in these patients. There was no association with the long-term outcome. [Correction added on 31 October 2013 after first online publication: In the Results section of the Abstract, the cohort of 797 patients in this study was corrected to 781 patients.]
    Type of Medium: Online Resource
    ISSN: 1747-4930 , 1747-4949
    URL: Article
    DOI: 10.1111/j.1747-4949.2012.00968.x
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2015
    detail.hit.zdb_id: 2211666-7
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  • 6
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    Do-Not-Resuscitate (DNR) Orders in Patients with Intracerebral Hemorrhage
    SAGE Publications ; 2014
    In:  International Journal of Stroke Vol. 9, No. 1 ( 2014-01), p. 53-58
    Details
    In: International Journal of Stroke, SAGE Publications, Vol. 9, No. 1 ( 2014-01), p. 53-58
    Abstract: Do-not-resuscitate orders may be associated with poor outcome in patients with intracerebral hemorrhage because of less active management. Aims We sought to characterize the practice of issuing do-not-resuscitate orders in intracerebral hemorrhage. We also aimed to identify possible differences in care according to do-not-resuscitate status. Methods We conducted a retrospective study of all consecutive intracerebral hemorrhage patients admitted to the Meilahti Hospital of the Helsinki University Central Hospital between January 2005 and March 2010. Data obtained from medical records allowed comparison of characteristics of patients and care of do-not-resuscitate and non-do-not-resuscitate patients as well as patients with early (within 24 h) and late ( 〉 24 h) do-not-resuscitate decisions. Logistic regression was used to identify factors independently associated with do-not-resuscitate decisions. Results Of our 1013 patients, a do-not-resuscitate order was issued in 368 (35%), of which 262 (73%) occurred within 24 h from admission. Advanced age (odds ratio 1.06 per year; 95% confidence interval 1.04–1.08), more severe stroke (1.09 per National Institutes of Health Stroke Scale point; 1.06–1.13), and deterioration soon after admission (5.12, 3.33–7.87) had the strongest associations with do-not-resuscitate decisions. Patients with do-not-resuscitate orders received recommended care including stroke unit care (43% vs. 64%; P 〈 0.001) and prophylaxis for deep venous thrombosis (45% vs. 54%; P = 0.027) less often than non-do-not-resuscitate patients. This was especially the case when the do-not-resuscitate order was issued early. Conclusions In addition to confirming the role of known intracerebral hemorrhage prognostic factors in do-not-resuscitate decision-making, our results demonstrate that do-not-resuscitate orders led to less active care of intracerebral hemorrhage patients.
    Type of Medium: Online Resource
    ISSN: 1747-4930 , 1747-4949
    URL: Article
    DOI: 10.1111/ijs.12161
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2014
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  • 7
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    European Stroke Organisation (ESO) Guidelines for the Management of Spontaneous Intracerebral Hemorrhage
    SAGE Publications ; 2014
    In:  International Journal of Stroke Vol. 9, No. 7 ( 2014-10), p. 840-855
    Details
    In: International Journal of Stroke, SAGE Publications, Vol. 9, No. 7 ( 2014-10), p. 840-855
    Abstract: Intracerebral hemorrhage (ICH) accounted for 9% to 27% of all strokes worldwide in the last decade, with high early case fatality and poor functional outcome. In view of recent randomized controlled trials (RCTs) of the management of ICH, the European Stroke Organisation (ESO) has updated its evidence-based guidelines for the management of ICH. Method A multidisciplinary writing committee of 24 researchers from 11 European countries identified 20 questions relating to ICH management and created recommendations based on the evidence in RCTs using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results We found moderate- to high-quality evidence to support strong recommendations for managing patients with acute ICH on an acute stroke unit, avoiding hemostatic therapy for acute ICH not associated with antithrombotic drug use, avoiding graduated compression stockings, using intermittent pneumatic compression in immobile patients, and using blood pressure lowering for secondary prevention. We found moderate-quality evidence to support weak recommendations for intensive lowering of systolic blood pressure to 〈 140 mmHg within six-hours of ICH onset, early surgery for patients with a Glasgow Coma Scale score 9–12, and avoidance of corticosteroids. Conclusion These guidelines inform the management of ICH based on evidence for the effects of treatments in RCTs. Outcome after ICH remains poor, prioritizing further RCTs of interventions to improve outcome.
    Type of Medium: Online Resource
    ISSN: 1747-4930 , 1747-4949
    URL: Article
    DOI: 10.1111/ijs.12309
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2014
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  • 8
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    Reliability of intracerebral hemorrhage classification systems: A systematic review
    SAGE Publications ; 2016
    In:  International Journal of Stroke Vol. 11, No. 6 ( 2016-08), p. 626-636
    Details
    In: International Journal of Stroke, SAGE Publications, Vol. 11, No. 6 ( 2016-08), p. 626-636
    Abstract: Accurately distinguishing non-traumatic intracerebral hemorrhage (ICH) subtypes is important since they may have different risk factors, causal pathways, management, and prognosis. We systematically assessed the inter- and intra-rater reliability of ICH classification systems. Methods We sought all available reliability assessments of anatomical and mechanistic ICH classification systems from electronic databases and personal contacts until October 2014. We assessed included studies’ characteristics, reporting quality and potential for bias; summarized reliability with kappa value forest plots; and performed meta-analyses of the proportion of cases classified into each subtype. Summary of review We included 8 of 2152 studies identified. Inter- and intra-rater reliabilities were substantial to perfect for anatomical and mechanistic systems (inter-rater kappa values: anatomical 0.78–0.97 [six studies, 518 cases], mechanistic 0.89–0.93 [three studies, 510 cases] ; intra-rater kappas: anatomical 0.80–1 [three studies, 137 cases], mechanistic 0.92–0.93 [two studies, 368 cases] ). Reporting quality varied but no study fulfilled all criteria and none was free from potential bias. All reliability studies were performed with experienced raters in specialist centers. Proportions of ICH subtypes were largely consistent with previous reports suggesting that included studies are appropriately representative. Conclusions Reliability of existing classification systems appears excellent but is unknown outside specialist centers with experienced raters. Future reliability comparisons should be facilitated by studies following recently published reporting guidelines.
    Type of Medium: Online Resource
    ISSN: 1747-4930 , 1747-4949
    URL: Article
    DOI: 10.1177/1747493016641962
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2016
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  • 9
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    Endovascular treatment of cerebral sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia
    SAGE Publications ; 2023
    In:  European Stroke Journal
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    In: European Stroke Journal, SAGE Publications
    Abstract: There is little data on the role of endovascular treatment (EVT) of cerebral venous sinus thrombosis (CVST) due to vaccine-induced immune thrombotic thrombocytopenia (VITT). Here, we describe clinical characteristics and outcomes of CVST-VITT patients who were treated with EVT. Patients and methods: We report data from an international registry of patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March 2021 and 6 March 2023. VITT was defined according to the Pavord criteria. Results: EVT was performed in 18/136 (13%) patients with CVST-VITT (92% aspiration and/or stent retrieval, 8% local thrombolysis). Most common indications were extensive thrombosis and clinical or radiological deterioration. Compared to non-EVT patients, those receiving EVT had a higher median thrombus load (4.5 vs 3). Following EVT, local blood flow was improved in 83% (10/12, 95% confidence interval [CI] 54–96). One (6%) asymptomatic sinus perforation occurred. Eight (44%) patients treated with EVT also underwent decompressive surgery. Mortality was 50% (9/18, 95% CI 29–71) and 88% (8/9, 95% CI 25–66) of surviving EVT patients achieved functional independence with a modified Rankin Scale score of 0–2 at follow-up. In multivariable analysis, EVT was not associated with increased mortality (adjusted odds ratio, 0.66, 95% CI 0.16–2.58). Discussion and conclusion: We describe the largest cohort of CVST-VITT patients receiving EVT. Half of the patients receiving EVT died during hospital admission, but most survivors achieved functional independence.
    Type of Medium: Online Resource
    ISSN: 2396-9873 , 2396-9881
    URL: Article
    DOI: 10.1177/23969873231202363
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2023
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  • 10
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    Mast Cell Blocking Reduces Brain Edema and Hematoma Volume and Improves Outcome after Experimental Intracerebral Hemorrhage
    SAGE Publications ; 2007
    In:  Journal of Cerebral Blood Flow & Metabolism Vol. 27, No. 4 ( 2007-04), p. 795-802
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    In: Journal of Cerebral Blood Flow & Metabolism, SAGE Publications, Vol. 27, No. 4 ( 2007-04), p. 795-802
    Abstract: Intracerebral hemorrhage (ICH) is associated with high mortality and disability, and there is no widely approved clinical therapy. Poor outcome after ICH results mostly from a mass effect owing to enlargement of the hematoma and brain swelling, leading to displacement and disruption of brain structures. Cerebral mast cells (MC) are resident inflammatory cells that are located perivascularly and contain potent vasoactive, proteolytic, and fibrinolytic substances. We previously found pharmacological MC stabilization and genetic MC deficiency to be associated with up to 50% reduction of postischemic brain swelling in rats. Here, we studied the role of MC and MC stabilization in ICH using in vivo magnetic resonance imaging and ex vivo digital imaging for calculating brain edema and hematoma volume. In a rat ICH model of autologous blood injection into the basal ganglia, four groups of Wistar rats received either saline or sodium cromoglycate (MC stabilizer, two groups) or compound 48/80 (MC degranulator). Evaluated 24 h later, MC stabilization had resulted in highly significantly better neurologic scores ( P 〈 0.001), decrease mortality ( P = 0.002), less brain swelling ( P 〈 0.001), and smaller hematoma volume growth ( P 〈 0.001) compared with saline and compound 48/80. Moreover, to support our hypothesis, we induced ICH in MC-deficient rats and their wild-type littermates (WT). MC-deficient rats responded with significantly better neurologic scores ( P 〈 0.001), decrease mortality (0% versus 25%), less brain swelling ( P 〈 0.05), and smaller hematoma growth ( P 〈 0.05) than WT. The role of MC deserves a close evaluation as a potential target in the development of novel forms of ICH therapy.
    Type of Medium: Online Resource
    ISSN: 0271-678X , 1559-7016
    URL: Article
    DOI: 10.1038/sj.jcbfm.9600387
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2007
    detail.hit.zdb_id: 2039456-1
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