Risultati per: Infezione da Helicobacter pylori: review

Stroke, Volume 53, Issue Suppl_1, Page AWMP44-AWMP44, February 1, 2022. Introduction:Vagus nerve stimulation (VNS) is a surgical technique that has been used to modulate disease processes by activating the parasympathetic system and has been used to treat conditions such as epilepsy and depression. More recently, VNS has been a promising tool in ischemic stroke rehabilitation. However, there has been no literature summarizing the adverse effects of this procedure, information that is critical for both patients and providers when obtaining informed consent for this novel treatment. This systematic review and meta-analysis aims to report the adverse effects of VNS.Methods:A systematic review was performed in accordance with PRISMA guidelines in order to identify common complications after VNS therapy. The search was executed in three databases: Cochrane Central Register of Controlled Trials, Embase, and Ovid MEDLINE. All prospective, randomized controlled trials using implanted VNS therapy in adult patients were eligible for inclusion. Case studies and studies lacking complete complication reports were excluded. Extracted data included technology name, location of implantation, follow-up duration, purpose of VNS, and adverse event rates.Results:After title-and-abstract screening of 4933 studies identified by the created search strategy, 21 studies were selected for final inclusion. Included papers studied VNS as a potential therapy for epilepsy (9), depression (8), anxiety (1), ischemic stroke (1), chronic heart failure (1), and fibromyalgia (1). In total, 1474 patients received VNS implantation in the 21 studies. The 5 most common post-implant adverse events were voice alteration/hoarseness (n=671, 45.5%), paresthesia (n = 233, 15.8%), cough (n = 221, 15.0%), dyspnea (n = 211, 14.3%), and pain (n = 170, 11.5%).Conclusions:Complications from VNS are relatively mild and transient, with reduction in severity and number of adverse events with increasing follow-up time. The most common complications included voice changes or hoarseness, increased cough, and pain with swallowing after surgery. In summary, VNS presents a powerful tool for the treatment of many difficult-to-treat conditions. In the future, the use of VNS in recovery after intracerebral hemorrhage should be explored.

Stroke, Volume 53, Issue Suppl_1, Page ATP147-ATP147, February 1, 2022. Background and Purpose:Endovascular thrombectomy (EVT) is an effective treatment for acute ischemic stroke (AIS) due to large vessel occlusion of the anterior circulation (AC-LVO). Randomized trials of posterior circulation large vessel occlusion (PC-LVO) patients have failed to show a benefit of EVT over medical therapy (MEDT). We performed a systematic review and meta-analysis to understand better whether EVT is beneficial for PC-LVO.Methods:Using the Nested Knowledge AutoLit living review platform, we identified randomized control trials and prospective studies that reported functional outcomes in patients with PC-LVO treated with EVT versus MEDT. The primary outcome variable was 90-day modified Rankin Scale (mRS) 0-3, and secondary outcome variables included 90-day mRS 0-2, 90-day mortality, and rate of symptomatic intracranial hemorrhage (sICH). A separate random effects model was fit for each outcome measure to calculate pooled odds ratios.Results:Three studies with 1,248 patients, 860 in the EVT arm and 388 in the MEDT arm, were included in the meta-analysis. The favorable outcome rate (mRS 0-3) in EVT patients was 39.9% (95% CI: 30.6-50.1%) versus 24.5% in MEDT patients (95% CI: 9.6-49.8%). EVT patients had higher mRS 0-2 rates (31.8% [95% CI: 25.7-38.5%] versus 19.7% [95% CI: 7.4-42.7%]) and lower mortality (42.1% [95% CI: 35.9-48.6%] versus 52.8% [95% CI: 33.3-71.5%]) compared to MEDT patients, but neither result was statistically significant. EVT patients were more likely to develop sICH (OR=10.36; 95% CI: 3.92-27.40).Conclusions:EVT treatment of PC-LVO trended toward superior functional outcomes and reduced mortality compared to MEDT despite a trend toward increased sICH in EVT patients. Existing randomized and prospective studies are insufficiently powered to demonstrate a benefit of EVT over MEDT in PC-LVO patients.

Stroke, Volume 53, Issue Suppl_1, Page ATMP74-ATMP74, February 1, 2022. Introduction:Direct oral anticoagulants (DOACs) have emerged as a potential anticoagulant therapy for patients with cerebral venous thrombosis (CVT). We conducted a systematic review and meta-analysis comparing DOACs versus vitamin K antagonists (VKAs) for treatment of CVT.Methods:We registered the review in PROSPERO (registration number CRD42021228800). We searched Medline, Embase, CINAHL, and the Web of Science Core Collection from January 1, 2007, to May 26, 2021. We included randomized controlled trials (RCTs) and non-randomized comparative studies (NRCSs) evaluating key outcomes for efficacy (recurrent venous thromboembolism [VTE] and complete recanalization) and safety (major hemorrhage). We assessed risk of bias using the Cochrane Risk of Bias Tool 2.0 (for RCTs) and the ROBINS-I tool (for NRCSs). Where studies were sufficiently similar, we performed meta-analyses using random-effects models. This review was funded by Brown Neurology.Results:Of 8213 identified records,10 studies (1 RCT and 9 NRCSs) with a total of 662 patients (33% DOAC and 67% VKAs) met the inclusion criteria. We will present our risk of bias assessment at the conference. DOACs and VKAs had comparable efficacy: recurrent VTE (risk ratio [RR] 1.00, 95% confidence interval [CI] 0.44-2.23; I2=0%; 10 studies) and complete recanalization (RR 1.00, 95% CI 0.77-1.28; I2=0%; 6 studies). DOAC and VKA also had comparable safety: major hemorrhage (RR 0.89, 95% CI 0.37-2.14; I2=0%; 9 studies).Conclusions:Studies comparing DOACs with VKAs in patients with CVT consist mostly of small, non-randomized, poorly controlled studies. While the two treatments appear comparable for major efficacy and safety outcomes, large, rigorously conducted studies, preferably randomized, are needed to overcome these limitations and permit development of clinical practice guidelines for the use of DOACs in patients with CVT.

Stroke, Volume 53, Issue Suppl_1, Page A76-A76, February 1, 2022. Introduction:The best stroke imaging modality to select patients for endovascular therapy (EVT) beyond 6 hours (extended window) is not well established.Objective:To assess the value of additional advanced imaging.Methods:A meta-analysis in accordance with PRISMA guidelines was conducted. We searched on MEDLINE/Pubmed, SCOPUS, EMBASE, CENTRAL, and reference lists until July 22, 2021, including randomized clinical trials (RCT) and observational studies describing 90 days outcomes in anterior circulation large vessel occlusion (LVO) ischemic stroke. Our primary outcome was functional independence, defined as modified Rankin Scale score (mRS): 0-2. Secondary outcomes were mortality and symptomatic intracranial hemorrhage (sICH). We used fixed effects model to estimate the pooled mRS for all patients and the proportion of patients with each outcome, both for all studies and by imaging modality.Results:Four RCTs (n=236) and 19 observational studies (n=1495) that met the inclusion criteria were included for meta-analysis. Patients selected by advanced imaging had a pooled estimate of functional independence in 45% (95% confidence interval [CI], 40% to 50% I2=62%), and 51% (95%CI, 43% to 60% I2=68.2%) without additional imaging. [Low certainty of evidence] Pooled mortality rate was 13% (95%CI,9% to 17%, I2=57.5%) vs 16% (95%CI,10% to 23%, I2=63.9), symptomatic intracranial hemorrhage (sICH) was 5% (95%CI,2% to 8% I2=33.6%) vs 4% (95%CI,2% to 7%, I2=66.4%) in both groups respectively [Low certainty] The overall pooled estimate of functional independence was 47% (95%CI, 43% to 52%, I2=65.2%) [Low certainty], with mean mRS of 2.88 (95%IC, 2.36 to 3.4) [moderate certainty] in all included patients indistinctly of the imaging modality.Limitations:substantial heterogenicity and not direct comparison of imaging modalities in most of the studies.Conclusion:This meta-analysis suggests that functional independence in patients with stroke who underwent EVT on the extended window can be achieved in a high proportion of patients despite the use or not of additional advanced imaging. Both groups also presented similar mortality and sICH.

Stroke, Volume 53, Issue Suppl_1, Page ATP49-ATP49, February 1, 2022. Background:With the advent of extended window endovascular therapy (EVT) for acute ischemic stroke (AIS), interhospital transfer is increasingly frequent. However, not all patients who are transferred undergo EVT. To use resources judiciously, stroke centers need to identify which patients are most likely to benefit from EVT prior to transfer.Methods:We performed a retrospective study of AIS patients transferred for potential EVT at our neurovascular center between 2015 and 2018. We noted whether pre-acceptance imaging was available for visual review on LifeImage, RAPID perfusion software, or Telestroke PACS. The primary outcome was EVT on arrival.Results:530 AIS patients were included. 270 underwent EVT (50.9%); 156 (29.4%) had pre-acceptance imaging reviewed; 275 (51.9%) received IVtPA. Of all patients who were transferred, performance of pre-transfer CTA was significantly associated with EVT (57% vs 40%, p

Stroke, Volume 53, Issue Suppl_1, Page A135-A135, February 1, 2022. Background:Endovascular thrombectomy is the gold standard treatment for acute ischemic strokes with large vessel occlusions (LVO). Manual image analysis is often time consuming and requires clinicians to be skilled in reading perfusion scans, as well as vessel images. RapidAI software has an automated processor to detect LVO of the middle cerebral artery and is analyzed in this study. A novel metric, number-needed-to-review (NNR), is introduced to assess the clinical efficiency of this software.Methods:This is a retrospective review of patients with a suspected ischemic stroke and an image processed by RapidAI software from 11/1/2020 to 4/30/2021 at a regional hospital system. Only M1 LVOs were included. Sensitivities, specificities, positive predictive value (PPV), and negative predictive value (NPV) were calculated for the following: Rapid LVO detection, gaze deviation (GD), hyperdense sign (HDS), Tmax >6 seconds, and NIHSS at presentation. The NNR was calculated for an M1 occlusion.Results:559 patients were included in this study. M1 occlusion was detected in 42 (7.5%) cases. Rapid LVO detection software was found to have a sensitivity of 71%, specificity of 94%, PPV of 49%, and NPV of 92% for a M1 occlusion. When both GD and HDS were combined with Rapid LVO, the specificity and PPV increased to 100% for a M1 occlusion. A negative LVO software combined with either a low (6s) or high (6s) Tmax threshold were found to have a specificity and PPV of 100% for no M1 occlusion. The combination of GD, HDS, Rapid LVO+ (for M1 occlusion) and Rapid LVO- with a low Tmax threshold (for no M1 occlusion) yielded 24 images NNR per 100 cases. When the combination of GD, HDS, Rapid LVO+ was combined with Rapid LVO- and a high Tmax threshold, the NNR per 100 cases was 16. With the addition of NIHSS6s threshold, the NNR is significantly decreased. As few as 9 images per 100 would be needed to be manually reviewed by a clinician during stroke triage.

Stroke, Volume 53, Issue Suppl_1, Page AWP89-AWP89, February 1, 2022. Introduction:Enrollment of populations that bear the real-world burden of ischemic strokes is critical to development of generalizable and clinically relevant randomized clinical trials (RCTs). Despite well-recognized historical patterns of underrepresentation for women, older adults, and certain racial/ethnic minorities, major knowledge gaps remain regarding representation in modern trials. We aimed to determine representativeness by age, sex, and race/ethnicity of participants in acute ischemic stroke RCTs performed in the US or CanadaMethods:We conducted a systematic review and meta-analysis in accordance with PRISMA, and prospectively registered with PROSPERO (CRD42021247730). ClincalTrials.gov was searched for ischemic stroke RCTs with acute interventions (

Stroke, Volume 53, Issue Suppl_1, Page AWP221-AWP221, February 1, 2022. Background:Early diagnosis through symptom recognition is vital in acute stroke management. However, women who experience stroke are more likely than men to receive a missed or delayed diagnosis.Aims:To assess sex differences in the symptom presentation of stroke and whether these differences are associated with a delayed or missed diagnosis.Methods:PubMed, EMBASE and the Cochrane Library were systematically searched up to January 2021 for all studies that reported on symptoms in both adult women and men with diagnosed stroke (ischaemic or haemorrhagic) and transient ischaemic attack and were published in English. Sex-stratified proportions for each symptom were extracted and pooled. The relative risk (RR) of a symptom being present in women relative to men with 95% confidence intervals (CI) was also calculated and pooled, as well as the RR of a delayed or missed stroke diagnosis.Results:Pooled results from 21 eligible articles showed that the top three symptoms were similar between women and men – limb weakness (72% vs. 66%), hemiparesis (56% vs. 55%), and weakness of the face, arm or leg (55% vs. 55%). However, the top 4th and 5th symptoms found in women were generalised non-specific weakness (49%) and motor deficit (46%), whereas in men these were motor deficit (46%) and ataxia (44%). In addition, crude RR showed that women were more likely to have higher risk than men of presenting with confusion (RR 1.16, CI 1.01-1.32), dysphagia (RR 1.29, CI 1.13-1.48), dysphasia (RR 1.11, CI 1.00-1.24), fatigue (RR 1.42, CI 1.05-1.92), generalised weakness (RR 1.56 CI 1.23-1.98), headache (RR 1.14, CI 1.01-1.30), urinary incontinence (RR 1.25, CI 1.17-1.33), loss of consciousness (RR 1.30, CI 1.12-1.51), and mental status change (RR 1.37, CI 1.18-1.58), and lower risk of presenting with dizziness (RR 0.87, CI 0.80-0.95), dysarthria (RR 0.89, CI 0.82-0.95), imbalance (RR 0.68, CI 0.57-0.81), paraesthesia (RR 0.74, CI 0.58-0.93), and trouble walking (RR 0.83, CI 0.70-0.99). Finally, pooled RR of delayed or missed diagnosis for women compared to men was not statistically significant (RR 1.19, CI 0.94-1.49).Conclusion:Though women and men commonly presented with similar symptoms, some sex differences were present which needs consideration in stroke evaluation.

Stroke, Volume 53, Issue Suppl_1, Page AWP62-AWP62, February 1, 2022. Introduction:Despite aerobic exercise (AE) testing being a key recommendation for stroke rehabilitation, less than half of physical therapists working with individuals post-stroke perform this practice. Concern for adverse cardiovascular events and inadequate guidance on how to conduct AE testing for individuals with stroke and comorbidity are key barriers. This review aims to describe submaximal AE testing protocols with evidence of safety, defined as less than 11% occurrence of serious adverse events, for people with subacute stroke and comorbidity.Methods:MEDLINE, EMBASE, PsycINFO, CINAHL and SPORTDiscus were searched from inception to October 29, 2020. Published studies that involved submaximal AE testing with individuals with subacute stroke and reported on adverse events during testing were included. Two reviewers independently conducted title and abstract, and full-text screening. One reviewer conducted data extraction, verified by a second reviewer.Results:Sixteen studies involving 595 participants were included. Hypertension (35%), cardiovascular disease (14%) and atrial fibrillation (8%) were the most common cardiovascular comorbidities, while, diabetes (25%), dyslipidemia (23%) and smoking history (11%) were the most common general comorbidities affecting participants with stroke. Evidence of safety for individuals with stroke and comorbidity was found for incremental bicycle (n=5), recumbent stepper (n=3), body weight support treadmill (n=1) and upper extremity ergometer (n=1) protocols; constant load bicycle (n=1) and body weight support treadmill (n=1) protocols; and field (n=10) protocols. Heart rate (95%), blood pressure (82%) and oxygen consumption (72%) monitoring were most frequently done. Test termination criteria based on volition/fatigue (59%) and heart rate (55%) were most commonly reported.Conclusion:A range of submaximal AE testing protocols utilizing diverse exercise modalities can be safely conducted on people with subacute stroke and comorbid conditions that are perceived to increase the risk for serious adverse events. These protocols can be used to guide the development of more specific clinical practice guidelines for conducting AE testing on individuals with stroke and comorbidity.

Stroke, Volume 53, Issue Suppl_1, Page AWP123-AWP123, February 1, 2022. Introduction:Whilst surgical decompression in malignant middle cerebral artery infarction is well established, its role in malignant posterior circulation infarction (MPCI) is unclear. Recent small cohort studies suggest that neurosurgery in this group may be beneficial. This systematic review and meta-analysis aims to compare outcomes of MPCI patients undergoing surgical intervention versus medical therapy.Methods:Medline, Embase and Cochrane were searched from inception until 2 April 2021. Studies were included if they evaluated patients with posterior circulation stroke treated with neurosurgical intervention. Observational cohort studies and case series with death and functional outcome data were included. Death was defined as Glasgow Outcome Scale (GOS) 1 and modified Rankin scale (mRS) 6, or extracted from the text. Favourable functional outcome was defined as mRS 0-2, GOS 4-5, Barthel Index 91-100 or extracted from text at the latest follow-up period. 6673 studies were filtered, with 31 studies included for data extraction, of which 8 studies included both a surgical and medical therapy group. Random effects meta-analysis, analysis of proportions and meta-regression were performed.Results:The medical therapy cohort (n=235) had significantly better odds of good functional outcome (GFO) than the surgical cohort. There was no significant difference in odds of death between the two groups (Figure 1). Amongst surgical patients (n=184), 18% died and 55% had GFO. On meta-regression, the proportion of patients with atrial fibrillation and hydrocephalus was negatively associated with odds of death and GFO respectively (both p

Stroke, Volume 53, Issue Suppl_1, Page AWMP4-AWMP4, February 1, 2022. Background and Purpose:Tenecteplase is being evaluated as an alternative intravenous (IV) thrombolytic agent for the treatment of acute ischemic stroke (AIS) within ongoing randomized controlled clinical trials. However, several research teams have published their real-world experience with tenecteplase for the treatment of AIS.Methods:We searched Medline and Scopus for non-randomized clinical trials and observational cohort studies (prospective or retrospective) comparing IV tenecteplase (at any dose) to IV alteplase for patients with AIS. We calculated the unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (95%CI) for the association of tenecteplase vs. alteplase use and outcomes of interest. We pooled estimates using random-effects models. The primary outcome was the probability of modified Rankin scale (mRS) score of 0-2 at 90 days. Non-inferiority of tenecteplase vs. alteplase for the primary outcome in the meta-analysis was set at margins of 1.3% and 5% based on a recent survey.Results:We identified 6 studies comparing IV tenecteplase (n=583) to IV alteplase (n=904). Patients receiving tenecteplase had higher odds of successful recanalization (OR=2.82, 95%CI: 1.12, 7.11; adjusted OR=2.38, 95%CI: 1.18, 4.81) and early neurological improvement (OR=4.88, 95%CI: 2.03, 11.71; adjusted OR=7.60, 95%CI: 1.97, 29.41) when compared to alteplase. Tenecteplase was non-inferior (when applying the 5% non-inferiority margin) to alteplase for the primary outcome of mRS 0-2 at 90 days (absolute risk difference=0.06, 95%CI: -0.04, 0.15; OR=1.20, 95%CI: 0.86, 1.67; adjusted OR=1.24, 95%CI: 0.88, 1.76). No difference in the risk of symptomatic intracranial hemorrhage was uncovered between the two groups (OR=0.96, 95%CI: 0.45, 2.07; adjusted OR=0.92, 95%CI: 0.47, 1.81).Conclusion:Real world evidence suggests that tenecteplase has a comparable efficacy and safety profile to alteplase for the treatment of AIS, while being possibly superior in achieving successful reperfusion and early neurological improvement.

Stroke, Volume 53, Issue Suppl_1, Page AWP179-AWP179, February 1, 2022. Background and Purpose:Prolonged cardiac rhythm monitoring can reveal a substantial proportion of ischemic stroke (IS) patients with atrial fibrillation (AF). We sought to evaluate the potential utility of available prolonged cardiac rhythm monitoring strategies with respect to secondary stroke prevention.Methods:We searched Medline and Scopus databases to identify randomized controlled clinical trials (RCTs) comparing AF detection, anticoagulation initiation and stroke recurrence rates in patients with history of recent IS or transient ischemic attack (TIA) receiving cardiac rhythm monitoring with implantable loop recorders (ILRs), 30-days external loop recorders or Holter monitors. We performed a network meta-analysis to combine direct and indirect evidence for any given pair of monitoring devices that were evaluated within a trial and reported effect estimates with risk ratios (RRs) and corresponding 95% confidence intervals (95%CIs).Results:We identified 5 RCTs including a total of 2202 patients (mean age 68 years, 40% women). In indirect analyses the likelihood of AF detection and anticoagulation initiation was higher for both ILR (RR=8.48, 95%CI: 3.41, 21.06; RR=3.29, 95%CI: 1.70-6.39) and external loop recorders (RR=3.06, 95%CI: 1.66, 5.61; RR=1.63, 95%CI: 1.03-2.58) compared to Holter devices. The probability of AF detection and anticoagulation initiation was lower for Holter and external loop recorders compared to ILR devices (RR=0.36, 95%CI: 0.15, 0.85 and RR=0.50, 95%CI: 0.25-0.98, respectively). No difference in the risk of stroke recurrence was found in the indirect comparisons of different cardiac rhythm monitoring strategies.Conclusion:The likelihood of AF detection and anticoagulation initiation after an ischemic stroke or TIA is higher with ILRs compared to both external loop recorders and Holter devices.

Stroke, Volume 53, Issue Suppl_1, Page ATP157-ATP157, February 1, 2022. Background:The evidence for mechanical thrombectomy in posterior circulation strokes is unclear. This systematic review and meta-analysis will summarise the available evidence for the use of mechanical thrombectomy in acute basilar artery occlusion.Objectives:To assess the effect of mechanical thrombectomy in acute basilar artery occlusion on disability, mortality, reperfusion and adverse events compared to best medical treatment (BMT).Search:We conducted a systematic review of randomised and prospective, clinically controlled trials using MEDLINE and EMBASE. We reviewed the Cochrane Central Register of Controlled Trials (CENTRAL), grey literature sources and reviewed the reference lists of key papers. No time limits or language restrictions were used.We used the modified Cochrane Collaboration tool to assess the risk of bias for randomised controlled trials and the The Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for prospective non-randomised clinical trials.Results:Five studies met the inclusion criteria (n = 1416). Three were cohort studies and two were randomised controlled trials. We used the random-effects model to combine the data. We found better functional outcome (mRS 0-3, 1.90 [1.07-3.35] p=0.03) and a trend towards decreased mortality (0.75 [0.62-0.91], p= 0.003) in the mechanical thrombectomy (MT) group. The improved outcomes were in the context of significant statistical heterogeneity driven by the difference in methodology between the trials. The improved outcomes were seen in the cohort studies. No significant difference in disability or mortality were found in the randomised controlled trials. We found higher reperfusion rates (TICI 2b/3: 4.75 [1.70-13.28] p=0.003) in the mechanical thrombectomy group with higher rates of symptomatic intracranial bleeding (3.90 [1.03-14.79] p=0.04).Conclusions:Our study reflects the complex nature of posterior circulation strokes and the lack of large randomised controlled trials in this field. We did find a trend towards better mortality and functional outcomes in the included cohort studies but this was not reflected in the randomised controlled trials. We also found higher reperfusion rates in the intervention groups with higher levels of sICH.

Stroke, Volume 53, Issue Suppl_1, Page AWP209-AWP209, February 1, 2022. Background:The optimal timing for the initiation of anticoagulation in patients with acute ischemic stroke (AIS) related to atrial fibrillation (AF) remains uncertain. Observational studies assessing early anticoagulant initiation (≤14 days after index AIS) have provided conflicting results from the early use of non-vitamin K oral anticoagulants (NOACs) or vitamin K antagonists (VKAs).Methods:We performed a meta-analysis of prospective observational studies and RCTs to assess the efficacy and safety of early anticoagulation in AF-related AIS. We also compared the efficacy and safety between NOAC and VKA regimens. A random-effects model was used to pool the individual risk ratios (RRs) and corresponding 95% confidence intervals (CIs) between the two groups. Recurrent ischemic stroke was defined as the primary outcome.Results:Nine eligible studies (7 observational, 2 RCTs) were identified, including 6,840 patients with AF-related AIS (pooled mean baseline NIHSS score: 5.5; 95%CI: 3.7-7.2) who received early anticoagulation. The overall ischemic stroke recurrence rate was 5% (95%CI: 3.3-7%) and differed (p=0.05) between studies reporting anticoagulation initiation within a week (2.5%, 95%CI: 0.2-7.4%) or two weeks (6.7%, 95%CI:4.6-9.1%) from index event. The corresponding proportions of patients experiencing a fatal outcome, symptomatic or asymptomatic ICH were 4% (95%CI: 1.6-7.5%), 1.2% (95%CI: 0.3-2.6%) and 13.2% (95%CI: 6.4-22.1%), respectively. Of the 2 identified RCTs, 136 and 135 patients were randomized to early anticoagulation with NOAC or VKA, respectively. Both groups had a similar risk for ischemic stroke recurrence (RR=0.78; 95%CI: 0.32, 1.91; p=0.59). No significant differences were uncovered between early NOAC or early VKA treatment initiation for the outcomes of mortality (RR=0.57; 95%CI: 0.11, 2.97; p=0.51), symptomatic ICH (RR=0.38; 95%CI: 0.02, 9.10; p=0.55) or asymptomatic ICH (RR=1.10; 95%CI: 0.73, 1.67; p=0.64).Conclusions:Preliminary evidence from RCTs on early anticoagulation after AF-related AIS suggest that NOACs have comparable efficacy to VKAs in preventing ischemic stroke recurrence. Large scale RCTs are warranted to evaluate the potential superiority of NOACs in terms of safety endpoints.

Stroke, Volume 53, Issue Suppl_1, Page AWMP26-AWMP26, February 1, 2022. Background and Purpose:When reviewing Code Stroke workflow data early in the COVID pandemic, a delay in obtaining CT brain imaging for stroke patients was identified. This study was aimed at improving Door-to-CT and Door-to-IVtPA bolus times by developing an Emergency Department (ED) led process improvement (PI) team to identify and track root causes for delays, provide feedback after fallouts, and recognize care teams after successful cases. Our primary goal was to demonstrate improved trends for performance metrics utilizing a novel method of process improvement, data collection, analysis, and dissemination.Methods:All ED patients activated as a Code Stroke were included in a weekly workflow review conducted by the PI team. Patients with a Door-to-CT of > 20 minutes were analyzed by the team via an in-depth chart review to identify the root cause of the delay. Specific metrics analyzed included Door-to-CT times and Door-to-IVtPA bolus times, along with the percentage of cases that met process metric time goals. Implementation of the weekly review began September 31, 2020, with the pre-implementation period corresponding to the prior nine months and the post-implementation period being the ensuing nine months. Metrics were analyzed using a control chart based on monthly metric averages, standard deviations (SD), and both an upper and lower control limit defined as 1 sigma level of variability from the average.Results:The average Door-to-CT time pre-implementation was 30.6 minutes versus 22.8 minutes post-implementation, with a percentage goal within 20 minutes pre- and post-implementation of 47% and 66%.The average Door-to-IVtPA Bolus time pre-implementation was 40.1 minutes versus 31.5 minutes post-implementation, with a percentage goal

Stroke, Volume 53, Issue Suppl_1, Page AWMP49-AWMP49, February 1, 2022. Background:D-dimer has been evaluated as an independent marker of ischemic stroke. The non-existence of a clear consensus and pooled data about the use of D-dimer as a predictive biomarker for assessing the risk of stroke recurrence led us to perform this systematic review and meta-analysis.Methods:Studies reporting the risk of stroke recurrence with varying degrees of high D-dimer levels were screened through August 2021 using PubMed/Medline, Scopus, EMBASE and Web of Science databases and relevant keywords. Random effects models by Dersimonian & Laird were used for meta-analysis and subgroup analysis. I2statistics were used for heterogeneity assessment. The leave-one-out method was used for sensitivity analysis.Results:This systematic review included 5040 patients from 9 studies consisting of >60% males. There was a high burden of cardiovascular comorbidities, smoking and diabetes in stroke patients with or without associated diagnoses and high D-dimer levels. Compared to low D-dimer levels, higher plasma D-dimer levels were associated with ~80% (aOR 1.79, 95% CI: 1.24-2.59) increased risk of stroke recurrence. The odds of stroke recurrence were significantly high in the stroke cohorts including patients with mean age