Risultati per: Linee Guida per le cure post-parto

Stroke, Volume 53, Issue Suppl_1, Page A3-A3, February 1, 2022. Introduction:Post-stroke depression affects one in three stroke patients and is associated with increased mortality and disability. Physical activity (PA) has been associated with fewer depressive symptoms after stroke, however, the long-term effect of pre-stroke PA and how Selective Serotonin Reuptake Inhibitors may affect this association is unknown.Methods:The study was conducted as a secondary analysis of data from The Efficacy of Citalopram Treatment in Acute Ischemic Stroke (TALOS) trial, where consecutive non-depressed acute ischemic stroke patients were randomized to Citalopram 20 mg or placebo for 6 months. Pre-stroke PA was measured using the Physical Activity Scale for the Elderly (PASE) and dichotomized by overall median value. Depressive symptoms were measured using the Major Depression Inventory (MDI) at one and six months after stroke. We used multivariable linear regression models to evaluate the interaction of pre-stroke PASE score and post-stroke MDI score.Results:We included 543 patients with complete PASE and MDI data at one month. Of these, 257 (47.3%) were in the SSRI group, 75% were men, and median (interquartile range) age was 69 (60 to 77). Overall, high PASE score was associated with lower MDI scores both one month (mean difference [confidence interval (CI)] -2.02 [-3.28 to -0.75]) and six months (-1.71 [-3.21 to -0.2]) after stroke. At one-month, a high PASE score was associated with lower MDI scores in the placebo group (mean difference -2.14 [-3.74 to -0.54]). After six months, an association between high pre-stroke PASE and lower MDI score was only found in the Citalopram group (mean difference -1.71 [-3.21 to -0.2]). Among patients with high pre-stroke PASE score the Citalopram group had lower MDI scores than the placebo group at six months (mean diff 2.01 [0.25 to 3.77]).Conclusions:High pre-stroke PA was independently associated with fewer depressive symptoms one and six months after stroke, however at six months the association was only present among those treated with Citalopram, suggesting an effect modification by Citalopram on the effect of PA on depressive symptoms. Further trials are warranted to verify these results.

Stroke, Volume 53, Issue Suppl_1, Page ATP162-ATP162, February 1, 2022. Background and Purpose:Angioplasty and stenting is a therapeutic option for patients with medically refractory intracranial atherosclerotic disease (ICAD). We previously demonstrated the feasibility of using Resolute (R) Onyx Stent, a drug-eluting balloon mounted coronary stent (DES), for ICAD patients. WEAVE (Wingspan Stent System Post Market Surveillance) trial assessed the periprocedural safety of Wingspan Stents in ICAD patients. We present our on-going experience with R-Onyx in ICAD patients integrating WEAVE styled methodology to assess outcomes in our cohort.Methods:A prospectively maintained neuro-endovascular database was queried for intracranial angioplasty and stenting cases from October 2019 to June 2021. Patients with symptomatic ICAD despite maximum medical management with >70% stenosis who were treated with R-Onyx DES were included. Primary outcomes were assessed according to WEAVE trial criteria (ischemic or hemorrhagic stroke or death within 72 h of the procedure). Secondary outcomes were assessed by occurrence of stroke and/or in-stent restenosis evaluated 30 days post-procedure clinically or angiographically.Results:A total of 58 patients were eligible for analysis with a mean age of 63.66 years, and 63.8% (n=37) were males. A total of 42 patients had an indication for treatment consisting of recurrent stroke while 16 had recurrent transient ischemic attacks. A total of 62 R-onyx DES stents were used to treat 58 patients with symptomatic lesions with an average stenosis of 84.7%. All procedures were completed successfully with

Stroke, Volume 53, Issue Suppl_1, Page AWP181-AWP181, February 1, 2022. Introduction:White matter hyperintensity (WMH), a radiographic marker of cerebral small vessel disease, is typically treated by modification of conventional cerebrovascular risk factors. However, the influence of dyslipidemia and the impact of 3-hydroxy-3-methylglutaryl-coenzyme-A reductase inhibitors (statins) on WMH is less certain. The goal of this study was to evaluate the influence of statins on progression of WMH over a four-year interval.Methods:We performed a post-hoc analysis of the SPRINT-MIND database for participants who had completed a baseline and a 4-year follow-up brain MRI with volumetric WMH calculations. Follow-up visits within this time window included data on medications, including statins. We defined statin usage as no therapy (0% of visits), partial therapy (1 – 99% of visits) or full therapy (100% of visits) based on this self-reported data. WMH progression was calculated as the difference in WMH volume between the two scans and then segmented into tertiles. ANOVA and chi-squared tests were used for continuous and categorical variables with adjustments made for variables known to influence WMH development.Results:425 individuals were included in this study: 53% (226/425) without statins use, 27% (115/425) with partial use and 20% (84/425) and full use. Demographic characteristics and baseline WMH volumes were similar amongst the cohort. With increasing statin use, a significant reduction in LDL was identified. Those with full statin use were significantly more likely to be in the top tertile of worse WMH progression (adjusted OR 2.30, 95% CI 1.11 – 4.77, p = 0.025).Conclusion:SPRINT-MIND participants prescribed a statin were nearly 2.5 times more likely to be within the top tertile of WMH progression over four years, despite adjustment for synergistic risk factors and improvement in LDL.

Stroke, Volume 53, Issue Suppl_1, Page A102-A102, February 1, 2022. Introduction:Treatment of uncontrolled arterial hypertension reduces the risk of cerebral small vessel disease (CSVD) progression, though it is unclear whether this reduction occurs due to blood pressure control or antihypertensive class-specific pleotropic effects. The goal of this study was to investigate the influence of antihypertensive medication class on accumulation of white matter hyperintensities (WMH), a radiographic marker of CSVD, within a cohort with well-controlled hypertension.Methods:Using the SPRINT-MIND dataset, we completed a post-hoc analysis of participants who completed a baseline and 4-year follow-up brain MRI with volumetric WMH data. Antihypertensive medication data were recorded at follow-up visits between the MRIs. A percentage of follow-up time participants were prescribed each of the eleven classes of antihypertensive was then derived. Progression of CSVD was calculated as the difference in WMH volume between two scans and, to address skew, dichotomized into a top tertile (greatest) accumulation and combined middle and bottom tertiles (slowest) accumulation.Results:Among 448 individuals included in this study, vascular risk profiles were similar across WMH progression subgroups except age (70.1±7.9 years versus 65.7±7.3 years, p

Stroke, Volume 53, Issue Suppl_1, Page ATMP58-ATMP58, February 1, 2022. Background:Delirium is an acute cognitive disturbance frequently characterized by abnormal levels of motor activity and sleep-wake cycle disruption. However, the degree to which delirium affects activity patterns in the acute period after stroke is unclear. We aimed to examine these patterns in a cohort of patients with intracerebral hemorrhage (ICH).Methods:We enrolled 40 patients with supratentorial ICH and hemiparesis who had daily delirium assessments performed by expert clinicians. Continuous measurements of activity were captured using bilateral wrist actigraphs for the duration of each patient’s admission. Activity data were collected in 1-minute intervals, with “rest” intervals defined as periods with zero activity recorded. We compared differences in activity based on delirium status across multiple time intervals using linear regression models adjusted for age, ICH severity, and mechanical ventilation.Results:There were 312 total days of actigraphy monitoring, of which 233 (75%) were rated as days with delirium; 85% of patients (34/40) experienced delirium during their hospitalization. In multivariable analyses, delirium days were associated with 66.3 (95% CI 9.4-123.2) fewer total minutes of rest, including 6.1% (95% CI 2.3-9.9%) fewer minutes of rest during daytime periods (06:00-21:59) and 9.2% (95% CI 3.3-15.0%) fewer minutes of rest during nocturnal periods (22:00-5:59). In separate analyses for individual hourly intervals, delirium days were associated with significantly higher levels of activity across multiple consecutive time intervals, including 05:00-09:00 and 17:00-03:00. In subgroup analyses, hyperactive or mixed delirium was associated with fewer total daily minutes of rest compared to hypoactive delirium, along with lower proportions of time at rest during both daytime and nocturnal periods (4.3% [95% CI 0.5-8.0%] and 6.5% [95% CI 0.9-12.1%] lower, respectively).Conclusion:Post-stroke delirium is associated with less rest and higher overall levels of activity, especially during nocturnal periods and in patients with hyperactive or mixed delirium.

Stroke, Volume 53, Issue Suppl_1, Page ATP258-ATP258, February 1, 2022. Background:Behavior tests that assess side-specific motor impairments after unilateral lesion such as focal ischemic stroke have translational applications, as 8 out of 10 stroke survivors suffer from hemiparesis. Accurate measurements of neurological functions are therefore important for assessing the effectiveness of various treatment strategies. Here, we demonstrate the feasibility of the staircase test to objectively evaluate lateralized deficits in coordinated paw reaching in adult mice after experimental stroke.Methods:A cohort of adult male C57BL/6J mice (12-14 weeks of age) were subjected to a 14-day training period, where they were kept on a 21-hour food deprivation regime and at 85-90% of their original body weight. They were then subjected to permanent distal middle cerebral artery occlusion (dMCAO, n=10). The number of steps reached and pellets grasped/eaten were evaluated at pre-stroke baseline and post-stroke days (PD) 7-8 and 14-15; behavior data from PD7-8 and PD14-15 were averaged between the two days. Brains were collected at PD16 and sections immunostained with antibodies targeting neurons (MAP2) and/or activated microglia/macrophage (CD68).Results:Mice attained a stable baseline for reaching steps and consuming pellets after a 14-day training period. At PD7-8, stroked mice showed a significant decrease in their ability to grasp/consume pellets on the affected side (right limb) compared to pre-stroke baseline (p=0.001). At PD14-15, stroked mice exhibited a significant decline in their ability to reach longer distances on the affected side (right limb), attaining only 65% of their baseline performance (p=0.006). No significant deficit was shown on the non-affected side (left limb).Conclusions:Our results show that the staircase test can detect side-specific motor deficits up to PD15 in a dMCAO model. Ongoing studies with a larger cohort are evaluating longer-term deficits up to one-month post-stroke and assessing the effects of optogenetic cortico-thalamic circuit stimulations on grasping behavior using the staircase test.

Stroke, Volume 53, Issue Suppl_1, Page AWMP24-AWMP24, February 1, 2022. Introduction:Depression is common after stroke, and is a debilitating factor undermining recovery in approximately one third of stroke survivors. It is essential to understand the underlying mechanisms to develop better treatments. Such insight may come from identifying plasma proteins correlated with post-stroke depression. Previous work investigated inflammatory proteins.Methods:We recruited 85 subjects 5 months to 9 years after ischemic stroke, age >40, and able to perform cognitive testing. Mood was assessed with the Stroke Impact Scale (SIS3), transformed to a 100-point scale. Plasma was analyzed by O-link proteomics for 1011 proteins. Multivariable regression models were constructed to estimate SIS3 using proteomics and clinical data. Models were subject to bootstrapping for robustness, and cross-validation to ensure results were reported on subjects blinded during model training. Pearson correlation analysis identified linear associations between individual proteins and SIS3 scores. We also report differences in key proteins in subjects dichotomized into non-depressed (SIS3 >63) or depressed (SIS3≤63) groups.Results:Proteomics results alone predicted SIS3 in multivariable models, and the best model also used age and time since stroke. A total of 180 proteins correlated significantly with SIS3. Plasma levels of IL-6 (p=0.0325), EGF (p

Stroke, Volume 53, Issue Suppl_1, Page ATP232-ATP232, February 1, 2022. Introduction:We previously reported a marked elevation of matrix metalloproteinases (MMP-1, MMP-7, MMP-8, MMP-9, MMP-11, MMP-12, and MMP-14) in the ischemic brain on day 3 after ischemic stroke in a rodent model. Also, we showed that MMP-12 suppression after ischemic stroke attenuates blood-brain barrier (BBB) disruption. The aim of the present study was to examine the effects of MMP-12 suppression on the expression of elevated M1 and M2 microglia/macrophage phenotypes and other MMPs in the ischemic brain. We hypothesized that MMP-12 suppression, by attenuating infiltrating leucocytes (especially monocytes), would decrease the expression of both M1 and M2 markers as well as other MMPs, since activated monocytes are the primary source of elevated MMPs in the ischemic brain.Methods:Young adult male Sprague-Dawley rats (n=6/group) were subjected to 2-h transient middle cerebral artery occlusion and received either MMP-12 shRNA (M12sh) expressing plasmids (1 mg/kg, i.v.; formulated as nanoparticles) within 30 min of reperfusion or no treatment. M12sh-treated and untreated ischemia-induced rats along with sham surgery rats were euthanized on day 3 after ischemia and brain tissues were collected for quantitative real-time PCR analysis of specific M1/M2 markers and various MMPs.Results:In untreated ischemia-induced animals, the expression of both M1 markers (CD16, CD68, IL-1β, IL-6, and TNFα) and M2 markers (CD163, CD206, Arg1, TGFβ, and IL-10) was increased approximately 10-150 fold over sham operated animals. Similarly, the expression of all MMPs studied (MMP-1, MMP-7, MMP-8, MMP-9, MMP-11, and MMP-14) was elevated approximately 10-30 fold in untreated ischemia-induced animals. M12sh treatment reduced the expression of most M1/M2 markers, notably CD68, IL-10, Arg1, and TGFβ, compared to no treatment. M12sh treatment also strongly reduced the elevated levels of MMP-7, MMP-9, MMP-11, and MMP-14.Conclusions:Suppression of MMP-12 leads to a general downregulation of M1/M2 markers and MMPs in the ischemic brain. We attribute these effects to reduced monocyte infiltration and subsequent inflammation. Suppression of MMP-12 could prove to be a promising therapy for ischemic stroke.

Stroke, Volume 53, Issue Suppl_1, Page AWP121-AWP121, February 1, 2022. Background:Traditionally, bed rest after emergency ischemic stroke treatments has been defined as 24 hours hours. The scientific basis for this timeline has not been established and practices may vary. We sought to determine bed rest practices following emergency stroke therapy in centers across the United States.Methods:We surveyed hospitals in the StrokeNet system regarding bed rest practices following acute stroke thrombolysis and/or thrombectomy. An anonymous survey (SurveyMonkey®) was sent out by the central coordinating center to all StrokeNet participating centers across the United States. Survey questions included stroke center designation, location of admission, whether a formal bed rest protocol was in place, minimum bed rest period required, which person first mobilized the patient, average duration of bed rest, which factors would alter duration of bed rest.Results:48 centers responded to the survey including 45 Comprehensive Stroke Centers and 3 Primary Stroke Centers. Most patients were admitted to a neuro-intensive care unit (69%), and others to a general medical/surgical ICU or stroke ward. 60% of respondents indicated that a formal bed rest policy was in place. Minimum bed rest requirements after thrombolysis alone ranged from 0-24 hours (43% with a 24 hour bed rest protocol, 20% with no minimum, 15% with a 12 hour minimum, 5% with an 8 hour minimum, 5% with a 6 hour minimum, and 12% with an indeterminate response). Similar variations were reported in patients undergoing thrombectomy with ranges from 0-24 hours bed rest. First mobilization was by a nurse 52% of the time and by a physical therapist 48% of the time. Actual mobilizations ranged from 0-36 hours after treatment. The most common factors that altered bed rest duration were: hemodynamic factors ( > 90% of respondents depending on the scenario) and NIHSS score ( > 65% depending on the scenario).Conclusion:Bed rest practices following emergency ischemic stroke treatment vary significantly across stroke centers. Mobilization of patients is performed primarily by nurses and therapists. Major factors that influence bed rest duration include hemodynamic factors and NIHSS score. Further study regarding an optimal approach for bed rest is warranted.

Stroke, Volume 53, Issue Suppl_1, Page A32-A32, February 1, 2022. Background:Disability can impact stroke survivors’ quality of life and mental health and may lead to suicide. Identifying and treating people at risk is one of the strategies listed by the Centers for Disease Control and Prevention to reduce suicide. The objectives of this study were to estimate the burden of suicide among stroke survivors in Georgia, identify predisposing factors, determine when patients are more likely to die of suicide, and examine suicide circumstances.Methods:Clinically diagnosed ischemic stroke (IS) patients from the Georgia Coverdell Acute Stroke Registry were linked with the Georgia Violent Death Reporting System (GVDRS) and death data for a retrospective cohort study. We applied survival analysis to estimate the annual suicide rate and cox proportional hazard model to identify high risk groups for suicide among stroke survivors. For those who died by suicide, circumstances were analyzed descriptively.Results:A total of 68,122 IS patients, from 2011 to 2018, were included. The median follow-up period was 40 months, and 70 suicide deaths were observed with a suicide rate of 28.3/100,000 person-years. About two-thirds of the suicides happened within 2 years of the stroke incident. Whites (HR=3.4), males (HR=10.8), young adults (HR=2.8), patients with depression (HR=3.8), and those who left hospitals against medical advice (HR=5.6) were more likely to die by suicide compared to blacks, females, older adults, patients without depression, and those who were discharged home respectively. Depression was reported in 36% of deaths, of which 25% had a past medical history of depression at hospital admission for stroke or were discharged with an antidepressant prescription. Firearms were used in 86.4% of the suicides.Conclusion:Ischemic stroke survivors have a 30% higher risk of death by suicide compared to the general Georgia population. This increased risk is mainly among males, patients with depression, and those who left hospitals against medical advice. More than four out of five suicides are by firearm; therefore, it is reasonable to make screening for suicide and counseling on firearm safety for patients and caregivers be a part of the discharge process and post discharge follow-up.

Stroke, Volume 53, Issue Suppl_1, Page A155-A155, February 1, 2022. Background:Randomized trials have shown that dual antiplatelet therapy (DAPT) reduces the risk of subsequent ischemic stroke in patients with minor stroke or high-risk TIA (MS-TIA). However, the 90 day risk remains elevated at 5-8%. In this exploratory study, we aimed to identify predictors of subsequent ischemic stroke in patients with MS-TIA treated with DAPT.Methods:This is a post-hoc analysis of the POINT trial that randomized patients with MS-TIA to DAPT versus aspirin monotherapy. For this analysis, we included only patients treated with DAPT and performed univariate and adjusted Cox-regression analyses to determine predictors of subsequent ischemic stroke. We also performed receiver operating analysis to determine predictive accuracy. P

Stroke, Ahead of Print. Background:The objective of this study was to evaluate factors associated with intraventricular hemorrhage (IVH) expansion and its association with long-term outcomes.Methods:We performed a post hoc analysis of the international, multi-center CLEAR III trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) which enrolled IVH patients between September 1, 2009, and January 31, 2015. The exposure was IVH expansion, defined as >1 mL increase in volume between baseline and stability computed tomography scans, before treatment randomization. We assessed factors associated with IVH expansion and secondarily assessed the relationship of IVH expansion with clinical outcomes: composite of death or major disability (modified Rankin Scale score, >3), and mortality alone at 6 months. The relationship of IVH expansion on ventriculoperitoneal shunt placement was additionally explored. Multivariable logistic regression was used for all analyses.Results:Of 500 IVH patients analyzed, the mean age was 59 (±11) years old, 44% were female and 135 (27%) had IVH expansion. In multivariable regression models, factors associated with IVH expansion were baseline parenchymal intracerebral hemorrhage (ICH) volume (adjusted odds ratio [OR], 1.04 per 1 mL increase [95% CI, 1.01–1.08]), presence of parenchymal hematoma expansion: >33% (adjusted OR, 6.63 [95% CI, 3.92–11.24]), time to stability head CT (adjusted OR, 0.71 per 1 hour increase [95% CI, 0.54–0.94]), and thalamic hematoma location (adjusted OR, 1.68 [95% CI, 1.01–2.79]) while additionally adjusting for age, sex, and race. In secondary analyses, IVH expansion was associated with higher odds of poor 6-month outcomes (adjusted OR, 1.84 [95% CI, 1.12–3.02]) but not mortality (OR, 1.40 [95% CI, 0.78–2.50]) after adjusting for baseline ICH volume, thalamic ICH location, age, anticoagulant use, Glasgow Coma Scale score, any withdrawal of care order, and treatment randomization arm. However, there were no relationships of IVH expansion on subsequent ventriculoperitoneal shunt placement (adjusted OR, 1.02 [95% CI, 0.58–1.80]) after adjusting for similar covariates.Conclusions:In a clinical trial cohort of patients with large IVH, acute hematoma characteristics, specifically larger parenchymal volume, hematoma expansion, and thalamic ICH location were associated with IVH expansion. Given that IVH expansion resulted in poor functional outcomes, exploration of treatment approaches to optimize hemostasis and prevent IVH expansion, particularly in patients with thalamic ICH, require further study.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT00784134.

Stroke, Ahead of Print. Background and Purpose:Hematoma volume (HV) is a powerful determinant of outcome after intracerebral hemorrhage. We examined whether the effect of the iron chelator, deferoxamine, on functional outcome varied depending on HV in the i-DEF trial (Intracerebral Hemorrhage Deferoxamine).Methods:A post hoc analysis of the i-DEF trial; participants were classified according to baseline HV (small 30 mL). Favorable outcome was defined as a modified Rankin Scale score of 0–2 at day-180; secondarily at day-90. Logistic regression was used to evaluate the differential treatment effect according to HV.Results:Two hundred ninety-one subjects were included in the as-treated analysis; 121 with small, 114 moderate, and 56 large HV. Day-180 modified Rankin Scale scores were available for 270/291 subjects (111 with small, 105 moderate, and 54 large HV). There was a differential effect of treatment according to HV on day-180 outcomes (P-for-interaction =0.0077); 50% (27/54) of deferoxamine-treated patients with moderate HV had favorable outcome compared with 25.5% (13/51) of placebo-treated subjects (adjusted odds ratio, 2.7 [95% CI, 1.13–6.27];P=0.0258). Treatment effect was not significant for small (adjusted odds ratio, 1.37 [95% CI, 0.62–3.02]) or large (adjusted odds ratio, 0.12 [95% CI, 0.01–1.05]) HV. Results for day-90 outcomes were comparable (P-for-interaction =0.0617). Sensitivity analyses yielded similar results.Conclusions:Among patients with moderate HV, a greater proportion of deferoxamine- than placebo-treated patients achieved modified Rankin Scale score 0–2. The treatment effect was not significant for small or large HVs. These findings have important trial design and therapeutic implications.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT02175225.

Comunicato del 12/10/2021 n°67