Risultati per: Il dolore neuropatico: review

Introduction
Infant mortality in low or middle-income countries (LoMICs) is still triple that of high-income countries (HICs), and the high mortality burden regions are also weighed down by a triple or quadruple burden of disease such as HIV and tuberculosis; chronic illness; mental health; injury and violence; and maternal, neonatal and child mortality. Emerging data suggest that the sudden unexpected death in infancy (SUDI) burden in LoMICs is at least 10-fold that in HICs. While ending preventable deaths in the neonatal period has received some global attention, the postnatal period where SUDIs occur is a poorly understood and data-poor area in LoMICs. We propose conducting a systematic review to evaluate the burden and trends of SUDIs in LoMICs since 2004.

Methods and analysis
We will systematically search PubMed, Web of Science, Scopus, African Index Medicus, EBSCOHost, Google Scholar, WHOIS and WHO database to identify studies published from July 2004 until October 2024. Two reviewers will screen titles and abstracts and select full-text articles independently for review. We will use the tool developed by the South African Medical Research Council—Burden of Disease Review Manager (BODRevMan)—to assess the risk of bias for each included study. Risk of bias will be assessed for each included study. Information on the prevalence and/or incidence of SUDI and its subcategories and case definitions will be extracted from each article. Where possible, data on prevalence, incidence and subcategories will be pooled using a random effects meta-analysis to account for variability between estimates. The I2 statistic will establish the level of heterogeneity due to variation in estimates rather than chance. Results will be presented in tables and graphs. The systematic review will be reported according to the PRISMA 2020 checklist.

Ethics and dissemination
Ethical approval is not required as this is a protocol for a systematic review. Findings will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO registration number
CRD42023466162.

Objective
This study examined real-world treatment patterns and outcomes in patients with melanoma brain metastasis (MBM) treated with first-line immunotherapy consisting of nivolumab plus ipilimumab or anti-programmed death-1 (PD-1) monotherapy (nivolumab or pembrolizumab) or targeted therapy consisting of BRAF/MEK inhibitors.

Design
Retrospective chart review study.

Setting
Academic medical centres, community hospitals and private practice offices.

Participants
Included patients diagnosed with melanoma with brain metastasis in the USA.

Outcome measures
The statistical analysis was descriptive in nature. Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method and compared between treatments in a univariate Cox proportional hazards model.

Results
In total, 472 patients with MBM who received first-line nivolumab plus ipilimumab (n=246), anti-PD-1 monotherapy (n=112) or BRAF/MEK inhibitors (n=114) were identified. Patients receiving nivolumab plus ipilimumab, compared with patients receiving anti-PD-1 monotherapy or BRAF/MEK inhibitors, had favourable baseline prognostic factors, such as younger age, fewer or smaller brain metastases, better Eastern Cooperative Oncology Group performance status and less frequently elevated lactate dehydrogenase. Median follow-up times were 15.4 months (range 0.1 to 37.0), 13.3 months (range 0.3 to 36.6) and 13.9 months (range 1.9 to 36.5), respectively. Numerically longer OS was observed with nivolumab plus ipilimumab versus anti-PD-1 monotherapy (HR 0.47, 95% CI 0.34 to 0.67) or BRAF/MEK inhibitors (HR 0.72, 95% CI 0.50 to 1.04) and numerically longer PFS was observed with nivolumab plus ipilimumab versus anti-PD-1 monotherapy (HR 0.74, 95% CI 0.53 to 1.02) or BRAF/MEK inhibitors (HR 0.82, 95% CI 0.60 to 1.12). With nivolumab plus ipilimumab, anti-PD-1 monotherapy and BRAF/MEK inhibitors, 1-year OS rates were 79%, 60% and 72%, respectively; 1-year PFS rates were 68%, 58% and 59%.

Conclusions
In this real-world study, first-line nivolumab plus ipilimumab appeared to provide benefit versus anti-PD-1 monotherapy and BRAF/MEK inhibitors in patients with MBM, consistent with pivotal trial data. However, the observed benefit may have been due to confounding and selection bias, given that patients receiving nivolumab plus ipilimumab had favourable baseline prognostic factors compared with patients receiving anti-PD-1 monotherapy or BRAF/MEK inhibitors.

Objectives
To provide an overview of research, policies and programmes related to the sexual and reproductive health (SRH) needs of adolescents and youth (AY) in South Sudan in order to identify the gaps and potential areas of focus for researchers, policymakers and local and global SRH actors.

Design
Systematic scoping review following the Joanna Briggs Institute criteria for evidence synthesis.

Data sources
Medline, Embase and Global Health were searched for articles dated between 9 July 2011 and 13 July 2023. A grey literature search was conducted using Google search engine and on the websites of key stakeholders.

Eligibility criteria for selecting studies
We included all types of studies, policies, reports and programmes that pertained to any aspect of the SRH AY (ages 10–35) in South Sudan.

Data extraction and synthesis
All articles were screened by the first author using the predetermined eligibility criteria. A secondary review was conducted on all selected articles to ensure alignment with criteria. Data were extracted from all eligible articles using an established data extraction tool. The authors identified overarching themes from the extracted data and results were synthesised based on those themes.

Results
We screened 728 articles, resulting in 52 articles included in the review (19 peer-reviewed, 33 grey literature). Results were mapped across South Sudan and synthesised by key AYSRH thematic areas. The results were largely focused on the experiences of adolescent girls and young women and the sociocultural norms and economic challenges that contribute to their lack of access to SRH services and increased risk of experiencing various forms of gender-based violence. Vulnerable populations were excluded from research, policies and programmes, including very young adolescents, LGBTQ youth and youth with disabilities.

Conclusions
Quality research has been done on AYSRH in South Sudan; however, there are many key areas that have not been addressed such as maternal mortality and morbidities, safe abortion and tailored interventions for specific subgroups. While some policies and programmes were identified that address AYSRH, robust programme evaluation processes or evidence of follow-through or implementation of government strategies are lacking.

Objectives
Population ageing and the rise in chronic diseases place continual stress on healthcare systems. Scarce resources often impede equitable access to healthcare, particularly in rural areas, resulting in prolonged waiting times and heightened risks of morbidity and mortality. Telemedicine has emerged as a promising solution, offering remote and equitable care that could potentially bridge access gaps and enhance health outcomes. This systematic review aims to quantitatively examine the impact of telemedicine implementation on waiting times, defined as the time passed from the booking of a visit for an outpatient to the administration of the service.

Design
A systematic review was conducted using studies on telemedicine interventions that specifically addressed waiting times. Bias assessment was performed with three tools: ROBINS-I (“Risk of Bias In Non-Randomized Studies of Interventions”), AXIS (“Appraisal tool for Cross-Sectional Studies”) and RoB-2 (“Risk of Bias-2”). A weighted mean approach was used to synthesise results, with medians synthesised using a median approach.

Data sources
Articles in English were retrieved from the PubMed and Scopus databases.

Eligibility criteria
Studies were excluded if they did not specifically address waiting times related to telemedicine interventions. Only studies that considered waiting times defined as the time passed from the booking of a visit for an outpatient to the administration of the service and any telemedicine intervention were included.

Data extraction and synthesis
A total of 53 records were included, encompassing 270 388 patients in both the experimental and control groups. The weighted mean reduction in waiting times was calculated, and bias was assessed. No record was evaluated to be at high risk of bias, with 69.8% of studies evaluated at low risk and 26.4% at moderate risk (3.8% were surveys). Results were synthesised using a weighted mean approach for studies reporting means, and a median approach for studies reporting medians.

Results
Overall, a weighted mean reduction of 25.4 days in waiting times was observed. Focusing on clinical specialties (n=114 042), the weighted mean reduction amounted to 34.7 days, while in surgical patients (n=156 346), telemedicine was associated with a weighted mean of 17.3 days saved.

Conclusions
The implementation of telemedicine solutions may significantly improve waiting times, potentially leading to more efficient and equitable healthcare systems.

PROSPERO registration number
CRD42023490822.

Stroke, Volume 56, Issue Suppl_1, Page ATMP35-ATMP35, February 1, 2025. Introduction:Studies have suggested efficacy of glycoprotein IIb/IIIa antagonists such as tirofiban for patients with acute ischemic stroke (AIS). However, neurological deterioration is still common in many of the recommended antiplatelet regimens. We aimed to evaluate the efficacy and safety of tirofiban versus dual antiplatelet therapy (DAPT) or aspirin in patients with AIS.Methods:Following PRISMA guidelines, we searched Pubmed, Embase, Scopus and Cochrane databases for studies comparing effects of tirofiban versus DAPT or aspirin alone in patients with AIS. Main outcomes were increase in NIHSS score, Modified Rankin Scale (mRS) scores at 90 days (0 to 2), intracranial hemorrhage (ICH) and mortality. Statistics analysis was performed using Review Manager 5.4.1 software. Heterogeneity was assessed with I2statistics.Results:We included 5 RCT and 5 non-RCT studies covering 1,857 patients, of whom 926 were treated with Tirofiban. Neurological deterioration, assessed by changes in NIHSS scores from baseline across four studies, was less pronounced in the Tirofiban group (MD -0.32; 9% CI -0.83-0.19; p

Stroke, Volume 56, Issue Suppl_1, Page ATP320-ATP320, February 1, 2025. Background:The kynurenine (KYN) pathway serves as the primary route for tryptophan (TRP) metabolism and plays a crucial role in the occurrence and development of several nervous diseases. The alterations in this pathway have been confirmed in psychiatric disorders, but their role in stroke remains unclear. This review aims to investigate whether metabolites in the TRP-KYN pathway change in patients with stroke.Methods:We searched PubMed, MEDLINE, Web of Science, Chinese Biomedical Literature Database, Chinese National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang databases for studies that compare the levels of KYN pathway metabolites between stroke and healthy volunteers. The primary outcome of this study was KYN, and the secondary outcome were TRP, kynurenine/tryptophan ratio (KYN/TRP), and kynurenic acid (KYNA). The Stata software was utilized for data synthesis.Results:Seven full-length articles with a total of 1080 participants (767 with stroke and 313 healthy volunteers) were included. The results indicated that compared to the control group, stroke patients had significantly lower levels of TRP (standardized mean difference (SMD)=-1.64; 95% CI [-2.36, -0.93];P

Stroke, Volume 56, Issue Suppl_1, Page ATMP23-ATMP23, February 1, 2025. Background:Swift intervention is crucial to achieving optimal outcomes in patients presenting with an acute ischemic stroke due to large vessel occlusion (LVO). The goal of this real-world, retrospective, records-based study was to assess process components driving door-to-reperfusion times across 16 facilities.Methods:A total of 1,362 patient records from a large healthcare system between August 2020 to December 2021 were reviewed retrospectively across 16 facilities throughout the United States. Each facility (n=16) completed a 196-question care pathway survey with clear differentiation between direct arrival and interfacility transfer modes of arrival. Elastic Net Regularization was used to account for patient-level characteristics in a subsequent multi-variable linear regression, revealing care pathway indicators associated with decreased door-to-reperfusion times. Actionable indicators were categorized and ranked using statistically significant coefficients and p-values. Confounders, (e.g. facility-related volume, level of stroke certification) were accounted for in the analysis and, subsequently, results were interpreted by a 16-member Nurse Working Group and an 8-member Physician Working Group. Preferred practice recommendations for thrombectomy-capable facilities were generated.Results:Overall, mean reperfusion rate (TICI 2B or higher) was 90.3% and mean door-to-reperfusion time was 116 minutes (SD ± 56, 108 mins (71, 152)). Mean door-to-puncture time was 83 minutes (74 min, (43,109)). Significant and highly-ranked care pathway indicators were classified into three categories: people, process, and technology. Programs with evidence of (1) full integration of CT techs into stroke alerts; (2) neuro-dedicated personnel prior to and at time of arrival; (3) standardized intake and communication protocols from door to puncture; (4) remote access for rapid imaging interpretation; and (5) established protocols for baseline imaging and anesthesia were associated with significantly higher time efficiencies across the continuum-of-care.Conclusions:Establishing evidence-based, preferred practices for mechanical thrombectomy across each care segment from door to recanalization can enhance stroke care pathway tactics to optimize patient outcomes. Future work will be to evaluate changes in time to reperfusion post-implementation of these preferred practices and to assess impact on patient outcomes.

Stroke, Volume 56, Issue Suppl_1, Page AWP9-AWP9, February 1, 2025. Background:Acute ischemic stroke can result from extracranial arterial dissection. The effectiveness and safety of intravenous thrombolysis (IVT) for acute ischemic stroke in these cases, particularly those involving large vessel occlusions, are debated. We conducted a systematic review and metanalysis to assess the efficacy and safety of IVT in patients with acute ischemic stroke attributed to extracranial arterial dissection.Methods:This systematic review was registered in PROSPERO (CRD42024499774). We searched MEDLINE (OVID), EMBASE, web of Science, and SCOPUS from inception to 03/03/2024. Search terms included a combination of keywords and controlled vocabulary terms for carotid or vertebral artery dissection and fibrinolysis or alteplase or tenecteplase. We included randomized controlled trials, observational studies, case series that compared IV thrombolysis and standard management with at least 10 patients in each group in patients with cervical or vertebral artery dissection. Where studies were sufficiently similar, we performed metanalyses for benefits (excellent (0-1) and good (0-2) modified Rankin scale at 90 days), safety (symptomatic intracerebral hemorrhage (sICH)), and mortality outcomes, using relative risks (RR). Given the impact of NIHSS on 90-day modified Rankin Scale, we pooled adjusted ORs (adjusting for NIHSS) when exploring 90-day functional outcomes.Results:Our search identified 418 records, we screened 12 studies as potentially eligible. Four studies (all retrospective cohort, 3 studies adjusted for NIHSS variable, one study addressed LVO cohort) met our inclusion criteria. The risk of bias was assessed using the Risk of Bias in Nonrandomized Studies of Interventions tool. Two studies had serious risk of bias while the other two had a moderate bias risk. When compared no IVT, IVT was associated with comparable risk of sICH (RR, 0.91 [95% CI, 0.11-7.94]) and mortality (RR, 0.63 [95% CI, 0.29-1.37]). However, IVT was associated with a significantly higher odds of good functional outcome at 90-days (aOR, 1.53 [95% CI, 1.14-2.05]) and a non-significantly lower chance of excellent functional outcome at 90-days (aOR 2.16 [95% CI 0.72-6.51]).Conclusion:Our metanalysis suggests that in patients with acute ischemic stroke secondary to extracranial artery dissection, IVT may have improved efficacy but comparable safety and mortality. Our findings should be interpreted with caution until supported by randomized controlled trials.

Stroke, Volume 56, Issue Suppl_1, Page ATP110-ATP110, February 1, 2025. Introduction:Cardiovascular comorbidities are highly prevalent in patients who suffer from cerebrovascular disease. Peak oxygen uptake (VO2peak) is a well-established, independent predictor of cardiovascular health and premature mortality. Dyslipidemia also contributes significantly to cardiovascular disease risk. Although previous studies have demonstrated improvements in these parameters with any exercise, the evidence remains inconclusive regarding which exercise intensity offers the greatest benefit. This systematic review and meta-analysis aims to compare the effects of high-intensity training (HIT) with other exercise intensities, including moderate intensity (MIT) and usual activity (UA).Methods:We systematically searched the PubMed, Cochrane, Embase, and Scopus databases for studies comparing HIT with MIT or UA in stroke patients. We evaluated changes from baseline in VO2peak, serum LDL, and HDL levels. Additionally, a separate analysis comparing HIT with MIT and UA was conducted for VO2peak.Results:A total of eight studies, involving 338 patients, were included in our analysis, with 163 (48%) of these patients undergoing HIT. The pooled analysis revealed that VO2peak was significantly higher in the control group compared to the HIT group, with a mean difference (MD) of 2.01 ml/kg/min (95% CI: 0.85-3.18, p < 0.01). Further analysis of four studies comparing HIT with MIT and three studies comparing HIT with UA showed that VO2peak was significantly higher following MIT (MD 2.03; 95% CI: 0.70-3.35; p < 0.01) and UA (MD 3.73; 95% CI: 0.87-6.59; p = 0.01). A separate analysis of three studies involving 148 patients showed no significant difference in serum LDL levels (MD 0.51; 95% CI: -0.46-1.49; p = 0.30) or serum HDL levels (MD -0.02; 95% CI: -0.16-0.13; p = 0.83).Conclusion:High-intensity training, based on a moderate sized pooled sample, does not offer superior advantages in changes from baseline in cardiopulmonary parameters compared to different exercise intensities. Future well-structured randomized controlled trials are needed to evaluate different exercise intensities and durations for more definitive conclusions. Nevertheless, the early data seems to indicate that there are no differences between exercise modalities.

Stroke, Volume 56, Issue Suppl_1, Page ATP113-ATP113, February 1, 2025. Background:Persistent gait impairments affect nearly half of stroke survivors six months post-stroke, despite standard rehabilitation. Intermittent theta burst stimulation (iTBS), a specialized form of repetitive transcranial magnetic stimulation (TMS), has shown promise in enhancing neural circuit activity and promoting long-term potentiation. While traditionally targeting the primary motor cortex, recent studies suggest that cerebellar iTBS may further improve gait and balance by modulating cerebello-cortical pathways.Aim:This meta-analysis aims to evaluate the efficacy of cerebellar iTBS in improving gait and balance in stroke patients.Methods:We conducted a systematic search in PubMed, Embase, and the Cochrane Library until August 2024, following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Included studies were peer-reviewed randomized controlled trials (RCTs) that assessed the effects of cerebellar iTBS on balance, assessed using the Berg Balance Scale; gait, measured through 3D gait analysis and the Timed Up and Go (TUG) test; and activities of daily living, assessed via the Barthel Index, in post-stroke patients with persistent gait and balance impairments. Meta-analyses were performed using a random-effects model.Results:Seven RCTs involving a total of 230 post-stroke patients (iTBS group, n=115) were included in this meta-analysis. The analysis revealed a significant improvement in balance (standardized mean difference [SMD] = 1.20, 95% confidence interval [CI] 0.12 to 2.29, p = 0.03). However, the TUG test did not demonstrate a significant change (SMD = 0.04, 95% CI: -0.37–0.46, p = 0.83), potentially reflecting variability in baseline gait performance. The 3D gait analysis showed a favorable but non-significant trend towards step length improvement (SMD = 0.71, 95% CI: -0.82–2.23, p = 0.37). Notably, a significant enhancement was observed in activities of daily living (SMD = 1.24, 95% CI: 0.49–1.98, p = 0.001).Conclusions:This meta-analysis suggests that cerebellar iTBS significantly enhances activities of daily living in post-stroke patients, with a potential but less consistent impact on balance and gait. These findings highlight the promise of cerebellar iTBS as an adjunctive therapy in stroke rehabilitation, though further high-quality RCTs are needed to clarify its specific therapeutic benefits.

Stroke, Volume 56, Issue Suppl_1, Page ATP119-ATP119, February 1, 2025. Introduction:Informed consent is a cornerstone of modern clinical research, though ensuring consent has long been recognized as problematic. This is especially true for acute stroke trials, where the time-sensitive nature of treatment challenges traditional consent practices. The era of platform adaptive trials will likely add further complexity to acute stroke consent. Therefore, we sought to survey the literature for any empirical studies documenting research participants’ preferences around what content is most important to include in consent forms.Methods:We conducted a systematic review of the literature to identify empirical studies reporting patients’ opinions about what content is most important to include in consent forms for research participation. Eligible studies included surveys, focus groups, or interviews. Based on a review of consent form templates, we identified 18 elements that commonly appear in consent forms, and used these to guide our extraction of potential content.Results:Of the 1,444 studies screened by title and abstract, 35 were sent to full text review, and data were extracted from 17 studies. To determine the ubiquity of the importance of these topics, we counted if each of these topics appeared in the 17 papers. The most commonly mentioned items included risks (65%, 11/17 studies), potential benefits (53%, 9/17 studies), study procedures e.g. blood draws and imaging (47%, 8/17 studies), confidentiality (47%, 8/17 studies), study rationale (41%, 7/17 studies), and voluntariness (41%, 7/17 studies). The least important elements included information about the condition and investigator conflicts of interest.Conclusion:In the era of adaptive platform trials for acute stroke, there is the potential for consent forms to become incredibly lengthy and complex. This is the first systematic review of which we are aware that seeks to identify what information is most important to be included in consent forms to participate in research studies. Unfortunately, data are limited but they suggest that consent form optimization is possible. Only risks and potential benefits were identified as important in a majority of studies.

Stroke, Volume 56, Issue Suppl_1, Page ATP106-ATP106, February 1, 2025. Background:Post-stroke cognitive impairment is especially devastating for young adult patients, who are in their most productive years. Despite its significant impact, this remains under-studied in this growing and clinically distinct patient group.Methods:We systematically searched PubMed, Embase, Scopus, and Cochrane CENTRAL for studies including ischemic stroke patients aged 18-50 years from January 2000 to July 2024. This meta-analysis evaluated the pooled prevalence of post-stroke cognitive impairment (CogI) and specific cognitive domains, as well as the associations between baseline characteristics and CogI.Results:A total of 4 studies with 1060 patients were included in this systematic review and meta-analysis. Overall, 35.9% (95% CI 27.2-45.5; Figure 1) of patients experienced post-stroke CogI with a mean follow-up time of 11.7 months (95% CI 8.00-15.4). One study was not included in the meta-analysis of proportions of overall cognition as this information was not available. The prevalence for individual domains was: visuospatial construction (23.1%; 95% CI 14.7-34.4), episodic memory (18.5%; 95% CI 9.7- 32.5), delayed memory (16.0%; 95% CI 13.5-18.9), working memory (18.8%; 95%CI 11.8-28.6), and attention (9.3%; 95%CI 3.2-24.0) with a mean follow-up time of 8.11 months (95% CI 3.50-12.7). Male patients had significantly higher odds of CogI (OR 1.58, 95% CI 1.05-2.38, p=0.030; Figure 2). Hypertension, diabetes mellitus, current smoking and dyslipidaemia were not significantly associated with CogI.Conclusions:A significant proportion of young adult ischemic stroke survivors experience CogI. Longitudinal prospective cohort studies are needed to better characterise the post-stroke cognitive trajectory in this important group of patients.

Stroke, Volume 56, Issue Suppl_1, Page ATP153-ATP153, February 1, 2025. Background:According to the 2023 guidelines for the management of patients with aneurysmal subarachnoid hemorrhages (SAH), early treatment of ruptured aneurysms reduces the risk of repeated bleeds and facilitates treatment of delayed cerebral ischemia. Efficient aneurysm securement in the hospital setting is critical to survival; however, analysis of aneurysm timing and care in the pre-hospital setting is difficult. In this quality improvement study, we reviewed hospital data to improve our outcomes for patients with aneurysmal SAH.Methods:We conducted a retrospective analysis of hospital outcomes and stroke metrics for 72 patients with last known well times who underwent securement for aneurysmal SAH at a comprehensive stroke hospital in upper Midwest from Jan 2016 to Jul 2024. Data were compiled from multiple resources including Get-With-The-Guidelines®, chart abstraction, and internal healthcare databases. We compared 0-24 hours (n=49) and >24 hours (n=23) ‘Onset to Treatment’ groups using appropriate statistical tests and significance was determined using a two-sided alpha of 0.05.Results:Demographics (age, sex), cerebrovascular risk factors (hypertension) were similar between both groups. No differences were noted in the size or location of aneurysm. Interestingly, the symptom presentation (altered level of consciousness [48% (0-24), 26% ( >24)]) and severity were higher in 0-24 group, including the NIH stroke scale (p-0.04), Hunt and Hess score (p-0.06), and Glascow Coma Scale (p-0.05). Modified Rankin scale (mRS) least favorable outcomes (5 and 6) were higher in 0-24 group (33% [0-24],17.3% [ >24]) and more external ventral drains were placed (70% [0-24], 57% [ >24]), though no change in overall hospital outcomes was noted, including mRS at discharge and discharge disposition between the groups. No differences were noted in ‘Door to Treatment’ times between the groups (12 [0-24] vs 14 hours [ >24], p-0.16).Conclusion:At our hospital, there were no significant differences in overall outcomes for patients treated before or after 24 hours of symptom onset for aneurysmal SAH. Additionally, no impact of ‘onset to door’ times on hospital metrics for securement was noted. Lastly, an interesting trend in patients who arrived within 24 hours of symptom onset had a higher severity of symptoms, greater complications, and an increase in least favorable outcomes, suggesting the importance of early recognition and education regarding SAH presentations.

Stroke, Volume 56, Issue Suppl_1, Page ADP6-ADP6, February 1, 2025. Introduction:Stroke represents a major global public health challenge, with 12.2 million new cases, 6.5 million deaths, and over 143 million disabilities occurring annually, leading to significant economic and social repercussions. Structural racism deleteriously influences stroke care and outcomes, making it essential to integrate multicultural considerations throughout the stroke care continuum to enhance outcomes and reduce disparities. A document analysis was conducted to assess the extent to which stroke guidelines address cultural diversity in stroke care.Method:A document review of international stroke guidelines was employed based on the framework established by Steinberg et al. A Google search was conducted to identify international stroke care guidelines published in English within the last five years (2019 – 2024). The quality of these guidelines was assessed using the Appraisal of Guidelines for Research&Evaluation (AGREE-II) tool. Paired reviewers independently screened the guidelines and identified recommendations related to multicultural stroke care, defined as ‘practices aimed at ensuring care delivery is culturally competent, sensitive, safe, equitable, and adaptable’.Results:A total of twenty-five guidelines were included, with the majority originating from Western countries such as Australia, the United States, the United Kingdom, Canada, and various European societies. Only four of the twenty-five guidelines explicitly addressed multicultural considerations. Most of the recommendations were based on low levels of evidence or consensus and related to dietary and cultural considerations, and the management of diverse patient needs in stroke care.Conclusion:A paucity of recommendations for multicultural considerations in stroke care were identified. Current stroke care guidelines fail to address multiculturalism adequately, which may reflect the maturity of the available evidence to inform guideline recommendations. Further research is needed to identify enablers and barriers to incorporating multicultural considerations in stroke care and the development of future guidelines. New evidence is needed in this regard to improve clinical outcomes of diverse populations.

Stroke, Volume 56, Issue Suppl_1, Page A58-A58, February 1, 2025. Background:Acute ischemic stroke (AIS) is a leading cause of disability worldwide. While intravenous thrombolysis is recommended within 4.5 hours of symptom onset, many patients present beyond this window. Tenecteplase (TNK) has shown to be non-inferior to tissue plasminogen activator (tPA) in early treatment window. However, its efficacy and safety in the extended 4.5 to 24-hour window remain unclear.Methods:We conducted a systematic review and meta-analysis of published clinical trials investigating TNK administration in AIS patients between 4.5 to 24 hours of symptom onset. PubMed, Cochrane Library, Google Scholar, and ClinicalTrials.gov were searched from inception through June 23rd, 2024. Inclusion criteria were: (1) clinical trials, (2) published in English, (3) full-text available, and (4) TNK administration in AIS or transient ischemic attack patients within 4.5-24 hours of onset. Primary outcomes assessed were functional independence at 90 days (defined as a modified Rankin Scale [mRS] score of 0-2) and ordinal shift in the mRS. Safety outcomes included symptomatic intracranial hemorrhage (sICH). Random-effects models were used to calculate pooled odds ratios (OR) with 95% confidence intervals (CI).Results:Five clinical trials met inclusion criteria with a total of 1,197 patients (599 TNK, 598 best medical therapy). Mean age was 71 years, with 61.7% males and a median baseline NIHSS of 10. Studies varied in imaging selection criteria, using either MRI DWI/FLAIR mismatch or CTP imaging with different perfusion cut-off values. Additionally, the proportion of patients receiving EVT post-randomization varied among studies. TNK treatment was associated with increased functional independence at 90 days (OR 1.33, 95% CI 1.04-1.70, p=0.02), but no significant difference in overall mRS (standardized mean difference: 0.01, 95% CI -0.37 to 0.39, p=0.969). A trend towards increased sICH with TNK was observed, though not statistically significant (OR 2.16, 95% CI 0.96-5.05, p=0.06).Conclusion:This meta-analysis suggests that TNK might be safe and effective for AIS patients in the 4.5 to 24-hour time window, potentially offering improved functional outcomes without significant increase in sICH. Future research should focus on conducting large, multicenter randomized controlled trials with refined patient selection criteria and standardized imaging protocols, to more precisely access the risk-benefit profile of TNK in extended time window.

Stroke, Volume 56, Issue Suppl_1, Page A153-A153, February 1, 2025. Background:The efficacy and safety of thrombectomy compared to medical therapy in patients with acute ischemic stroke irrespective of the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) has been debated.Method:We systematically searched EMBASE, PubMed and Scopus for randomized controlled trials (RCTs) and observational studies evaluating the efficacy and safety of thrombectomy compared to medical therapy in patients with acute ischemic stroke irrespective of the ASPECTS score with primary outcomes of modified rankin scale (mRS) score 0-3 at 90 days, functional independence mRS score 0-2 at 90 days and symptomatic intracranial hemorrhage (sICH).Results:We included 20 RCTs and 6 observational studies containing 6580 patients comparing thrombectomy with medical therapy in patients with acute ischemic stroke irrespective of the ASPECTS scores. The pooled results showed that mRS score 0-3 at 90days (RR = 2.10; 95% CI [1.59; 2.77]; I2= 71%; p < 0.001; Figure 1A) and mRS score 0-2 at 90 days (OR = 2.48; 95% CI [1.97; 3.12]; I2= 64%; p < 0.001; Figure 1B) were significantly improved by thrombectomy compared to the medical therapy. Early neurologic worsening (RR = 0.93; 95% CI [0.57; 1.51]; I2= 63%; p = 0.770; Figure 1C) was not significantly different between groups. The safety outcome, sICH within 48hrs (RR = 1.82; 95% CI [1.25; 2.64]; I2= 50%; p = 0.002; Figure 2A) was significantly higher in thrombectomy group. The National Institutes of Health Stroke Scale (NIHSS) score at 24hrs (MD = -2.84; 95% CI [-4.11; -1.58]; I2= 65%; p < 0.001; Figure 2B) and mean change in infarct volume from baseline at 24hrs (MD = -26.10; 95% CI [-40.18; -12.02]; I2= 97%; p < 0.001; Figure 2C) were significantly reduced by thrombectomy. However, decompressive craniotomy (RR = 1.17; 95% CI [0.78; 1.75]; I2= 20%; p = 0.453; Figure 2D) did not show any difference between groups. Death within 90 days (OR = 0.71; 95% CI [0.61; 0.81]; I2= 22%; p < 0.001; Figure 3A) was significantly reduced by thrombectomy. The early neurologic improvement (SMD = 3.43; 95% CI [2.39; 4.93]; I2= 37%; p < 0.001) and median EuroQol Group 5 Dimension (EQ-5D) index at 90days (MD = 0.15; 95% CI [0.07; 0.23]; I2= 84%; p < 0.001; Figure 3C) were also improved by thrombectomy.Conclusion:Compared with medical therapy, thrombectomy may improve functional outcomes in patients with acute ischemic stroke irrespective of the ASPECTS scores, despite associated with an increased risk of sICH.