Rabinstein, Alejandro A.

Background Intracerebral hemorrhage (ICH) risk is higher in elderly patients with atrial fibrillation on antithrombotic therapy as well as those with cerebral amyloid angiopathy (CAA). We investigated if mortality among patients with atrial fibrillation on antithrombotic therapy presenting with non‐traumatic ICH was influenced by underlying CAA. Methods and Results We used the Rochester Epidemiology Project to identify 6045 patients with atrial fibrillation aged >55 years on anticoagulation or antiplatelet therapy from 1995 to 2016. Seventy‐four patients in this cohort presented with non‐traumatic ICH. Medical records including imaging data were reviewed to identify those with CAA and record baseline variables and outcomes of interest; 38 of our 74 patients (51.4%) (mean age 81.5 years) met Modified Boston Criteria for possible or probable CAA. Twenty‐six of 74 patients (35%) died during the first 30 days while 56 of the 74 (76%) patients died by 10 years follow‐up after index ICH. Overall mortality was not significantly different between the CAA and non‐CAA groups at any point of time during follow‐up ( P =0.89) even amongst patients restarted on anticoagulation +/− antiplatelet (n=19) ( P =0.46) or those patients restarted only on antiplatelet therapy (n=22) ( P =0.66). Three of the 41 patients who restarted on antithrombotic therapy had a recurrent ICH; these 3 patients met criteria for possible or probable CAA. Conclusions Although more than half of our patients with atrial fibrillation on antithrombotic therapy and non‐traumatic ICH met Modified Boston Criteria for CAA, CAA did not significantly influence the high mortality seen in this cohort.

Background To assess if leukoaraiosis severity is associated with outcome in patients with acute ischemic stroke (AIS) following endovascular thrombectomy, and to propose a leukoaraiosis-related modification to the ASPECTS score. Methods A retrospective review was completed of AIS patients that underwent mechanical thrombectomy for anterior circulation large vessel occlusion. The primary outcome measure was 90-day mRS. A proposed Leukoaraiosis-ASPECTS (“L-ASPECTS”) was calculated by subtracting from the traditional ASPECT based on leukoaraiosis severity (1 point subtracted if mild, 2 if moderate, 3 if severe). L-ASEPCTS score performance was validated using a consecutive cohort of 75 AIS LVO patients. Results 174 patients were included in this retrospective analysis: average age: 68.0±9.1. 28 (16.1%) had no leukoaraiosis, 66 (37.9%) had mild, 62 (35.6%) had moderate, and 18 (10.3%) had severe. Leukoaraiosis severity was associated with worse 90-day mRS among all patients (P=0.0005). Both L-ASPECTS and ASPECTS were associated with poor outcomes, but the area under the curve (AUC) was higher with L-ASPECTS (P<0.0001 and AUC=0.7 for L-ASPECTS; P=0.04 and AUC=0.59 for ASPECTS). In the validation cohort, the AUC for L-ASPECTS was 0.79 while the AUC for ASPECTS was 0.70. Of patients that had successful reperfusion (mTICI 2b/3), the AUC for traditional ASPECTS in predicting good functional outcome was 0.80: AUC for L-ASPECTS was 0.89. Conclusions Leukoaraiosis severity on pre-mechanical thrombectomy NCCT is associated with worse 90-day outcome in patients with AIS following endovascular recanalization, and is an independent risk factor for worse outcomes. A proposed L-ASPECTS score had stronger association with outcome than the traditional ASPECTS score.

Purpose Compare functional outcomes of acute ischemic stroke patients undergoing embolectomy with either local anesthesia or conscious sedation. Secondarily, identify differences in hemodynamic parameters and complication rates between groups. Materials and methods Single institution, retrospective review of all acute ischemic stroke patients undergoing embolectomy between January 2014 and July 2018 ( n = 185). Patients receiving general anesthesia ( n = 27) were excluded. One-hundred and eleven of 158 (70.3%) composed the local anesthesia group, and 47 (29.7%) composed the conscious sedation group. Median age was 71 years (interquartile range 59–79). Seventy-eight (49.4%) were male. The median National Institute of Health stroke scale score was 17.5 (interquartile range 11–21). Hemodynamic, medication, complication, and functional outcome data were collected from the anesthesia protocol and medical records. Good functional outcome was defined as a three-month modified Rankin Scale < 2. A multivariate analysis was performed to estimate the association of anesthesia type on three-month modified Rankin Scale score. Results Three-month modified Rankin Scale score <2 was similar between groups ( p = 0.5). Patients receiving conscious sedation were on average younger than patients receiving local anesthesia ( p = 0.01). Conscious sedation patients were more likely to receive intravenous thrombolytic prior to embolectomy ( p = 0.025). The complication rate and hemodynamic parameters were similar between groups. Conclusion Functional outcome of acute ischemic stroke patients undergoing embolectomy appears to be similar for patients receiving local anesthesia and conscious sedation. This similarity may be beneficial to a future study comparing general anesthesia to local anesthesia and conscious sedation. The use of local anesthesia or conscious sedation does not significantly impact hemodynamic status.

OBJECTIVE Recent population-based and hospital cohort studies have reported a decreasing incidence of aneurysmal subarachnoid hemorrhage (aSAH) and declining aSAH-associated case-fatality rates. Principal drivers of these trends are debated, but improvements in smoking cessation and hypertension control may be critical factors. METHODS The population-based medical records linkage system of the Rochester Epidemiological Project was used to document aSAH incidence and 30-day case fatality rates during a 20-year study period (1996–2016) in Olmsted County, Minnesota. Incidence rates in the study period were compared with data from a previous Olmsted County study concerning aSAH incidence from 1965 to 1995 and with regional trends in tobacco use. RESULTS One hundred nineteen incident cases of aSAH were included. The median age at hemorrhage was 59 years (range 16–94 years), and 74 patients were female (62.2%). The overall average annual aSAH incidence rate was 4.2/100,000 person-years (P-Y). The aSAH incidence rate decreased from 5.7/100,000 in 1996 to 3.5/100,000 P-Y in 2011–2016. The overall aSAH-associated 30-day case-fatality rate was 21.9% and declined by approximately 0.5% annually. An accelerated decline in the fatality rate (0.9%/year) was observed from 2006–2016. Smoking among adult Olmsted County residents decreased from 20.4% in 2000 to 9.1% in 2018. CONCLUSIONS A decline in the incidence of aSAH and 30-day case-fatality rate from 1996 to 2016 was observed, as well as an accelerated decline of the fatality rate from 2006 to 2016. These findings confirm and extend the trends reported by prior studies in the same population. The decrease in aSAH in the years studied paralleled a noticeable reduction in the population smoking rates.

Background Since 2015, endovascular therapy has been established as a standard of care for acute stroke. This has caused major challenges regarding the organization of systems of care, which have to meet the increasing demand for thrombectomies. This study aims to evaluate how endovascular therapy decisions made by European and North American physicians under their current local resources differ from those made under assumed ideal conditions. Methods In an international, multidisciplinary survey, physicians involved in acute stroke care were asked to give their treatment decisions to 10 out of 22 randomly assigned stroke case-scenarios. Participants stated (a) their treatment approach under assumed ideal conditions (without any external limitations) and (b) the treatment they would pursue under their current local resources. Resources gaps (ideal minus current endovascular therapy rates) were calculated for different countries/states/provinces and correlated to economic and healthcare key metrics (gross domestic product-per-capita, public or private health insurance coverage, etc.). Results A total of 607 physicians, among them 218 from North America and 136 from 25 European countries, responded to the survey. Resources gaps in the majority of North American states/provinces and European countries were small (<5%). The highest gaps were observed among few European countries, namely Poland (30%) and the United Kingdom (33%). The magnitude of the resources gap did not correlate to national economic or healthcare metrics. Discussion and conclusion In the majority of North American states/provinces and European countries covered in this study, the discrepancy between endovascular therapy decisions under current local resources and assumed ideal conditions seems to be small, even in countries with a limited economic status and healthcare infrastructure.