Risultati per: Circulation

Introduction
Advances in the care of patients with single-ventricle congenital heart disease have led to a new generation of individuals living with a Fontan circulation. For people with Fontan physiology, physical, psychological and neurodevelopmental challenges are common. The objective of this study is to describe and develop a deeper understanding of the factors that contribute to quality of life (QOL) among children, adolescents and adults living with a Fontan circulation across Australia and New Zealand, their parents and siblings.

Methods and Analysis
This article presents the protocol for the Australian and New Zealand Fontan Registry (ANZFR) QOL Study, a cross-sectional, population-based study designed to examine QOL among people of all ages with a Fontan circulation, their parents and siblings. Study eligibility criteria includes (1) individuals with a Fontan circulation aged ≥6 years, at least 12 months post-Fontan procedure and enrolled in the ANZFR; (2) parents of individuals enrolled in the ANZFR; and (3) siblings aged ≥6 years of an individual enrolled in the ANZFR. A novel, online research platform is used to distribute personalised assessments tailored to participant age and developmental stage. A suite of validated psychometric self-report and parent-proxy report instruments capture potential correlates and predictors of QOL, including symptoms of psychological distress, personality attributes, coping and cognitive appraisals, family functioning, healthcare experiences and costs, access to emotional support and socioeconomic factors. Clinical characteristics are captured via self-report and parent-proxy report, as well as the ANZFR. Descriptive analyses and multilevel models will be used to examine QOL across groups and to investigate potential explanatory variables.

Ethics and Dissemination
Approval has been obtained from all relevant Human Research Ethics Committees (HRECs), including the Sydney Children’s Hospitals Network and the Royal Children’s Hospital Melbourne HRECs. Study findings will be published in peer-reviewed journals and presented at national and international meetings and seminars.

Objectives
Rapid changes in glucocorticoid (GC) levels and adrenal insufficiency are related to the development of post-cardiac arrest (CA) syndrome. However, GC receptor (GR) expression changes have not been studied. Hence, this study aimed to investigate the association of early changes in GR expression and prognosis and immune response in patients who experienced CA.

Design
Prospective observational study.

Setting
Emergency department.

Participants
Patients (85) in the early period of return of spontaneous circulation (ROSC) after CA were admitted between October 2018 and October 2019. After a physical examination, age-matched and sex-matched healthy individuals (40) were recruited for the control group.

Primary and secondary outcome measures
GR expression and cell counts of circulatory T and B lymphocytes, natural killer cells and regulatory T (Treg) cells were assessed. Plasma total cortisol and adrenocorticotrophic hormone (ACTH) levels were also tested.

Results
All cell counts were lower, and plasma total cortisol levels were higher (p

Stroke, Ahead of Print. Clinical outcomes of patients with acute ischemic stroke depend in part on the extent of their collateral circulation. A good collateral circulation has also been associated with greater benefit of intravenous thrombolysis and endovascular treatment. Treatment decisions for these reperfusion therapies are increasingly guided by a combination of clinical and imaging parameters, particularly in later time windows. Computed tomography and magnetic resonance imaging enable a rapid assessment of both the collateral extent and cerebral perfusion. Yet, the role of the collateral circulation in clinical decision-making is currently limited and may be underappreciated due to the use of rather coarse and rater-dependent grading methods. In this review, we discuss determinants of the collateral circulation in patients with acute ischemic stroke, report on commonly used and emerging neuroimaging techniques for assessing the collateral circulation, and discuss the therapeutic and prognostic implications of the collateral circulation in relation to reperfusion therapies for acute ischemic stroke.

Stroke, Ahead of Print.

Stroke, Ahead of Print. Background:In patients with large vessel occlusion stroke of the anterior circulation, underlying cause is a determinant of outcome. Whether this is the case for posterior circulation large vessel occlusion stroke has yet to be determined. We aimed to report on cause in patients with posterior circulation stroke treated with endovascular thrombectomy and to analyze the association with functional outcome.Methods:We used data of patients with posterior circulation stroke included in the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) registry, a prospective multicenter observational study, between 2014 and 2018. Stroke cause was categorized into large artery atherosclerosis (LAA), cardioembolism, arterial dissection, embolic stroke of undetermined source (ESUS), other determined cause, or undetermined cause. For primary analysis on the association between cause and outcome, we used multivariable ordinal logistic regression analysis to estimate the adjusted common odds ratio for a shift towards a better functional outcome on the modified Rankin Scale at 90 days with LAA as a reference group. Secondary outcomes included favorable functional outcome (modified Rankin Scale score 0–3), National Institutes of Health Stroke Scale score at 24 to 48 hours, reperfusion on digital subtraction angiography, and stroke progression.Results:Of 264 patients with posterior circulation stroke, 84 (32%) had LAA, 48 (18%) cardioembolism, 31 (12%) dissection, and 14 (5%) ESUS. Patients with a dissection were younger (48 [interquartile range, 43–60] years) and had a lower National Institutes of Health Stroke Scale at baseline (12 [interquartile range, 6–31]) than patients with other cause. Functional outcome was better for patients with cardioembolism and ESUS compared to LAA (modified Rankin Scale adjusted common odds ratio, 2.4 [95% CI, 1.1–5.2], respectively adjusted common odds ratio, 3.1 [95% CI, 1.0–9.3]). Patients with a dissection had a lower chance of successful reperfusion compared with LAA (adjusted odds ratio, 0.20 [95% CI, 0.06–0.70]).Conclusions:Unlike the anterior circulation, most frequent cause in our posterior large vessel occlusion stroke cohort is LAA followed by cardioembolism, dissection, and ESUS. Patients with cardioembolism and ESUS have a better prognosis for functional outcome after endovascular thrombectomy than patients with LAA.

Stroke, Ahead of Print. BACKGROUND:The optimal endovascular strategy for reperfusing distal medium-vessel occlusions (DMVO) remains unknown. This study evaluates angiographic and clinical outcomes of thrombectomy strategies in DMVO stroke of the posterior circulation.METHODS:TOPMOST (Treatment for Primary Medium Vessel Occlusion Stroke) is an international, retrospective, multicenter, observational registry of patients treated for DMVO between January 2014 and June 2020. This study analyzed endovascularly treated isolated primary DMVO of the posterior cerebral artery in the P2 and P3 segment. Technical feasibility was evaluated with the first-pass effect defined as a modified Thrombolysis in Cerebral Infarction Scale score of 3. Rates of early neurological improvement and functional modified Rankin Scale scores at 90 days were compared. Safety was assessed by the occurrence of symptomatic intracranial hemorrhage and intervention-related serious adverse events.RESULTS:A total of 141 patients met the inclusion criteria and were treated endovascularly for primary isolated DMVO in the P2 (84.4%, 119) or P3 segment (15.6%, 22) of the posterior cerebral artery. The median age was 75 (IQR, 62–81), and 45.4% (64) were female. The initial reperfusion strategy was aspiration only in 29% (41) and stent retriever in 71% (100), both achieving similar first-pass effect rates of 53.7% (22) and 44% (44;P=0.297), respectively. There were no significant differences in early neurological improvement (aspiration: 64.7% versus stent retriever: 52.2%;P=0.933) and modified Rankin Scale rates (modified Rankin Scale score 0–1, aspiration: 60.5% versus stent retriever 68.6%;P=0.4). In multivariable logistic regression analysis, the time from groin puncture to recanalization was associated with the first-pass effect (adjusted odds ratio, 0.97 [95% CI, 0.95–0.99];P

Stroke, Volume 53, Issue Suppl_1, Page AWP145-AWP145, February 1, 2022. Introduction:Acute basilar artery (BA) occlusion represents a catastrophic form of acute ischemic stroke. Mechanical thrombectomy (MT) for this disease is frequently performed, despite the lack of level I evidence. In this study, we aim to identify predictors of good outcome in patients with basilar artery occlusions who underwent MT within 24 hours from last seen normal.Method:We conducted a retrospective review study of patients who underwent MT for acute basilar artery occlusions, between October 2012 and October 2018 at our center. The primary endpoint was good functional outcome (modified Rankin Score < 3) at three months. Baseline demographics, clinical, procedural, and radiographic parameters were recorded. We performed a multivariate analysis to determine the predictors of good clinical outcome.Results:Our study included 62 patients with basilar artery occlusions treated within 24 hours from last seen normal: 58% of patients achieved good outcome at 90 days. Age, baseline NIHSS, baseline risk factors and rate of IV tPA administration were comparable between the two groups. Patients with good functional outcome at 90 days were less likely to have a history of stroke (13.9% vs 50%,p= 0.005), more likely to have a higher PC-ASPECTS (10 vs 8,p= 0.0003), and higher successful recanalization rate (91.7% vs 63.6%,p=0.01). There was a numerically higher number of patients who achieved good outcome within the early time window (less than 6 hours from last seen normal) compared to the 6-24hr time window (50% vs 31.8%, p=0.23). On multivariate logistic regression analysis, the only independent predictor of good functional outcomes was PC-ASPECTS (OR 2.65, 95 % CI 1.47- 4.75,p=0.00114).Conclusion:In our cohort of patients with BA occlusion who underwent MT, PC- ASPECTs was an independent predictor of good outcome. Prospective studies are warranted to validate our findings.

Stroke, Volume 53, Issue Suppl_1, Page ATP152-ATP152, February 1, 2022. Introduction:In posterior circulation stroke (PCS), large artery atherosclerosis at the occlusion site or dissection is most often reported as underlying stroke etiology, while cardio embolism is less common than in anterior circulation stroke (ACS). As thrombus characteristics are related to the underlying stroke etiology, we hypothesized that differences in radiological thrombus characteristics between PCS and ACS are fully explained by differences in underlying etiology. We compared radiological thrombus characteristics between PCS and ACS to gain insight in the differences in order to optimize treatment options for PCS.Methods:In patients treated with endovascular treatment (EVT) for acute ischemic stroke in the MR CLEAN Registry, radiological thrombus characteristics (perviousness, density, and length) were assessed on thin-slice (

Stroke, Volume 53, Issue Suppl_1, Page ATP221-ATP221, February 1, 2022. Background and Purpose:The difference among anterior and posterior circulation stroke regarding vascular risk factors is commonly known. Our aim is to verify the difference of clinical backgrounds between anterior and posterior circulation in hyperacute stroke with large vessel occlusion (LVO) caused by atherosclerotic occlusion (AO).Methods:This multicenter, retrospective study included LVO patients who were performed revascularization therapy (thrombectomy, intravenous thrombolysis, or both) between October 2017 and May 2021. The definition of AO was the fixed residual stenosis/occlusion at the initially occluded lesion confirmed in the second angiographic imaging performed 7 days later from symptom onset. The patients were dichotomized by LVO location, anterior or posterior. Traditional risk factors and laboratory data were compared.Results:Among the 1770 consecutive stroke patients admitted during the study period, 162 patients (104 men, median age 76 years old) were enrolled in our study. AO was diagnosed in 41 patients (25%; 27% of anterior circulation vs. 17% of posterior, P=0.291). In total cohort, patients with anterior circulation showed higher frequency of atrial fibrillation, lower glycosylated hemoglobin level, higher D dimer level, and higher brain natriuretic peptide level (Figure 1 black bar). The cohort of AO patients had a similar tendency (Figure 1 blue bar).Conclusion:One fourth of patients with LVO are AO. In anterior circulation stroke with AO, attention should be paid to stroke recurrence due to not only atherosclerosis but embolism.

Stroke, Volume 53, Issue Suppl_1, Page ANS4-ANS4, February 1, 2022. Introduction:Recognition of stroke alerts in triage are imperative to the rapid evaluation of acute ischemic stroke. Patients who present to the Emergency Department (ED) with a chief complaint of dizziness have historically been challenging for triage nurses. Missed triage opportunities may result in increased door to needle (DTN) times. The goal of this study was to assess if a dizziness triage tool can reduce missed posterior circulation strokes and decrease DTN times.Methods:We developed the following three questions: Is the room spinning, shaking, or are you lightheaded; does it come and go or is it persistent with sudden onset within the last six hours; does the dizziness change with position. If the description of dizziness was sudden, spinning/shaking, persistent, and non-positional, then the patient was triaged as a stroke. ED RNs were trained and education tools were distributed in January 2019. Data were retrospectively reviewed on patients who presented with dizziness, were diagnosed with posterior circulation strokes, and received IV Alteplase. Dizziness for this study was defined as: dizziness, dizzy, vertigo, lightheaded, room spinning, room shaking, unsteadiness, and/or imbalance. Data were reviewed pre and post implementation over a three-year period to assess the percentage of patients captured by the tool and its impact on DTN times. Data were analyzed using a t-test.Results:Patients with a Brain Alert were older (71 {IQR 59-74}) vs. No Brain Alert (57 {IQR 53-63} p=0.036) yrs. 86% of women had no brain alert whereas 62% of men did. The median NIHSS for Brain Alert was 3 (IQR 1-4) vs. no brain was 1 (IQR 1-4) (p=0.89). In the pre-implementation time frame 47% (7/15) of dizzy patients diagnosed with ischemic stroke and received alteplase were captured by a triage nurse activated brain alert. Post implementation 89% (8/9) and 100% (4/4) were captured in 2019 and 2020 respectively. Median DTN for dizzy patients improved from 56 mins in 2018 (IQR 44-92) to 46 mins in 2020 (IQR 36-60) p=0.025.Conclusion:A triage nurse three-question dizziness tool is successful and sustainable in identifying posterior circulation strokes in the emergency department which helps to decrease DTN times in these patients.

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 A126-A126, February 1, 2022. Introduction:Acute ischemic stroke due to basilar artery occlusion (AIS-BAO) results in significant morbidity and mortality. Endovascular thrombectomy (ET) has not been shown to improve outcomes in AIS-BAO patients in randomized trials, which may be due to insufficient selection before ET. We determined whether the Critical Area Perfusion Score (CAPS) and posterior circulation ASPECTS (PC-ASPECTS) predict a favorable response to ET.Methods:We performed a multicenter retrospective study of AIS-BAO patients with perfusion imaging prior to ET. PC-ASPECTS was determined on NCCT by evaluating the cerebellum (1 point/hemisphere), pons (2 points), midbrain (2 points), thalamus (1 point/hemisphere), and posterior cerebral artery (1 point/hemisphere) territories, and points were subtracted for hypodensity in these regions. CAPS was quantified severe hypoperfusion (Tmax >10s) in cerebellum (1 point/hemisphere), pons (2 points), midbrain and/or thalamus (2 points). The primary outcome was a favorable outcome 90-days after ET (modified Rankin Scale [mRS] 0-3).Results:89 patients were included. CAPS (AUC=0.70 [95% CI: 0.59-0.80]; p=0.002) and PC-ASPECTS (AUC=0.63 [95% CI: 0.52-0.75]; p=0.034) both predicted favorable outcomes in a receiver operating curve analysis, but there was no difference between the two (p=0.434). After dichotomization, patients with favorable CAPS (≤3) and PC-ASPECTS (≥7) were more likely to achieve a good functional outcome after successful reperfusion after ET (Figure). However, an unfavorable CAPS ( >3) was associated with poor outcomes despite successful thrombectomy in all patients, whereas 22% of patients with unfavorable PC-ASPECTS (

Stroke, Volume 53, Issue Suppl_1, Page AWP166-AWP166, February 1, 2022. Introduction:The relationship between pass number during endovascular therapy (EVT) and outcomes in anterior circulation large vessel occlusion (LVO) acute ischemic stroke (AIS) has been well studied. However, the association between number of thrombectomy attempts and outcomes for patients with posterior circulation LVO remains undetermined.Methods:From our prospective multi-institutional registry including 4 comprehensive stroke centers in the Houston area, we identified consecutive LVO AIS patients who underwent EVT (01/2018-06/2021). The number of thrombectomy passes and per-pass reperfusion grades (TICI) were recorded at time of the EVT procedure. The primary outcome was the effect of number of passes on functional independence (modified Rankin Scale 0-2) at 90 days. Secondary outcomes included likelihood of attaining substantial reperfusion (TICI ≥2b).Results:Among 894 LVO AIS patients who underwent EVT, median age was 68 [IQR 58-78], 49% were female, and median NIHSS was 16 [IQR 11-21]. Of this cohort, 86 had posterior circulation LVO including 65 with basilar artery occlusion and 9 vertebral artery. The diminishing benefit on reperfusion and functional outcome after additional EVT passes was similar for anterior and posterior circulation AIS (Figure 1). Among patients with posterior circulation LVO, successful reperfusion with fewer passes was associated with greater likelihood of good outcomes (41.9% vs 6.7% mRS 0-2 with 1-2 vs ≥3, p=0.012). The likelihood of good outcomes with 1-2 passes for patients with posterior circulation LVO was comparable to patients with anterior circulation LVO (41.9% vs 40.2%, p=0.164).Conclusions:Similar to patients with anterior circulation LVO, patients with posterior circulation LVO undergoing EVT are more likely to achieve functional independence with successful reperfusion in fewer EVT attempts. Overall clinical outcomes are significantly better with fewer passes regardless of occlusion location.

Stroke, Volume 53, Issue Suppl_1, Page AWP68-AWP68, February 1, 2022. Introduction:Posterior circulation strokes (PCS) are considered to have poor outcomes with high mortality and morbidity, but comparisons of functional outcome with anterior circulation strokes (ACS) have yielded conflicting results. Differences in demographics, cardiovascular risk factors and stroke etiology have been proposed, with ischemic PCS patients tending to be younger, more often male, and more frequently diabetic.Objectives:Describe the clinicodemographic profile and functional outcomes in PCS patients admitted to inpatient rehabilitation (IPR), and identify factors associated with functional change.Methods:A retrospective review of a database maintained on consecutive stroke patients admitted to IPR at Memorial Hermann-TIRR between 2017 and 2019 was conducted. Demographics, Functional Independence Measure (FIM) scores, and discharge disposition of 806 patients were assessed. Table 1 displays significance testing by univariate analysis. Baseline characteristics, pre-stroke mRS, NIHSS, admit FIM, and length of stay (LOS) in IPR were adjusted in regression models.Results and Conclusions:Results are summarized in Table 1. Diabetes and prior stroke or TIA occurred in higher percentages of patients with PCS, or concurrent ACS/PCS. NIHSS was higher in ACS patients with a mean of 9.6 (SD 7.1, p

Stroke, Volume 53, Issue Suppl_1, Page ATP220-ATP220, February 1, 2022. Background:Posterior circulation strokes (PCS) make up 20% of all strokes, yet there is poor understanding of what factors contribute to poor clinical outcomes. We investigated clinical and demographic characteristics associated with poor clinical outcomes in PCS using a population-based biracial cohort.Methods:Greater Cincinnati Northern Kentucky Stroke Study (GSNKSS) 2010 and 2015 data was utilized to identify 1842 patients who were >20 years old with MRI-proven PCS. Eligible patients were then stratified based on functional outcomes (modified Rankin Scale/= 3, with >= 3 considered poor) according to demographics, stroke risk factors, tPA treatment, stroke location, and stroke mechanism. A multivariable logistic model was used to identify the predictors for poor functional outcomes.Results:Age, higher NIHSS, higher baseline mRS, hypertension, temporal, thalamus, and brainstem location, and cardioembolic mechanism were associated with poor clinical outcomes (Table). After multivariable analysis, age, higher NIHSS, higher baseline mRS, hypertension, temporal, thalamus, and brainstem location, and cardioembolic mechanism remained associated with poor outcomes.Conclusion:Understanding these factors associated with poor prognosis after posterior circulation stroke will allow for better prognostication and family counseling.

Stroke, Volume 53, Issue Suppl_1, Page AWP153-AWP153, February 1, 2022. Background:Almost half of large-vessel occlusion (LVO) stroke patients have unfavorable outcomes despite successful endovascular revascularization. We aim to characterize post-revascularization cerebral blood flow (CBF) determined by transcranial Doppler (TCD) and explore whether abnormal CBF associates with in-hospital outcomes in this population.Methods:We analyzed 105 stroke patients with anterior circulation LVO who had successful endovascular revascularization (Thrombolysis in Cerebral Infarction 2b-3) and CBF assessment by TCD within 48 hours of recanalization. TCD parameters recorded at the ipsilateral middle cerebral artery included mean flow velocity, peak systolic velocity, pulsatility index (PI), and resistance index (RI). CBF was classified according to the Thrombolysis in Brain Ischemia (TIBI) score into dampened flow (score of 3), stenotic flow (score of 4), and normal flow (score of 5). We explored unadjusted associations between post-revascularization CBF and hospitalization outcomes including reduced disability at discharge (modified Rankin Score [mRS] 0-2), home disposition, and in-hospital mortality.Results:Table 1 summarizes study population characteristics. Overall, 62 (59.1%) individuals had normal CBF, 29 (27.6%) had stenotic flow, and 14 (13.3%) had dampened flow. Patients with abnormal CBF showed a trend towards lower likelihood of mRS 0-2 at discharge (32.1% vs. 44.2%; p=0.20) and home disposition (28.1% vs. 46.6%; p=0.08). TCD parameters were not associated with disability at discharge or home disposition. However, in-hospital mortality was significantly associated with elevated PI (1.3 ± 0.4 vs. 1.1 ± 0.5; p