Liebeskind, David S

Background: Previous reports have established a relationship between asymptomatic high-grade carotid artery stenosis (CAS) and impaired cognition. Different forms of cardiac disease have also been associated with cognitive impairment and dementia. The effect of concurrent high-grade CAS and cardiac disease on cognition is unknown. We hypothesize the presence of comorbid cardiac disease has a synergistic effect on cognitive impairment in patients with asymptomatic CAS. Methods: Patients with ≥80% internal carotid artery stenosis with no history of stroke were recruited from inpatient and outpatient practices at a single, large, comprehensive stroke center. Patients with vs without comorbid cardiac disease (coronary artery disease [CAD], CAD with history of coronary artery bypass graft [CABG] or percutaneous intervention [PCI], heart failure [HF], atrial fibrillation [AF], or valvular disease [aortic or mitral]) were identified. Cognitive assessments were performed using a battery of 14 standardized tests of attention, memory, processing speed, visual construction, language and executive function. Z-scores were generated based on age-specifc norms. Multivariable linear regression was used to compare test-specific Z-scores in patients with vs without cardiac disease controlling for age, sex, years of education and depression. Results: Thirty-three patients with asymptomatic CAS were identified (21 males, age 74+/-10 years, education=16+/-3 years). Twenty-six (79%) had cardiac disease. Patients with comorbid cardiac disease had significantly lower Z-scores across multiple tests of memory compared to patients without cardiac disease (Fig). After adjusting for age, sex, years of education and depression, significant differences persisted in tests of memory in patients with CAD [Hopkins Recognition Memory Test, β= -1.127 (95% CI: -2.234, -0.020), P=0.046], CABG [Hopkins Learning Trial Memory Test, β= -1.441 (95% CI: -2.532, -0.350), P=0.012], and valvular disease [Hopkins Learning Trials Memory Test, β= -1.121 (95% CI: -2.224, -0.018), P=0.047]. Conclusion: Cardiac disease is common among patients with asymptomatic high-grade carotid stenosis and may have a synergistic effect on impairments in memory in a manner not mediated by stroke. Further work is needed to confirm these relationships and their longterm implications on vascular brain health.

Background: There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines. Aims: To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced). Summary of review: Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited. Conclusion: The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.

Background: Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation. Methods: STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0–2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass. Results: A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients ( P <0.001). Clinical outcomes were better in the direct group, with 60.0% (299/498) achieving functional independence compared with 52.2% (213/408) in the transfer group (odds ratio, 1.38; 95% confidence interval, 1.06–1.79; P =0.02). Likewise, excellent outcome (modified Rankin Score 0–1) was achieved in 47.4% (236/498) of direct patients versus 38.0% (155/408) of transfer patients (odds ratio, 1.47; 95% confidence interval, 1.13–1.92; P =0.005). Mortality did not differ between the 2 groups (15.1% for direct, 13.7% for transfer; P =0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier. Conclusions: In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02239640.