Rabinstein, Alejandro A.

Background and Purpose— There is uncertainty whether warfarin-treated patients (despite international normalized ratio <1.7) have increased risks of symptomatic intracerebral hemorrhage after intravenous thrombolysis. Methods— Vascular risk factors, stroke subtype, and outcome measures were compared between warfarin- and nonwarfarin-treated patients undergoing acute thrombolysis within 3 hours of symptom onset. Results— From 212 patients (mean age, 74±14 years; 50% men) studied, 14 (6.5%) had prior warfarin use. After adjusting for age, baseline National Institutes of Health Stroke Scale, and stroke subtype, warfarin-treated patients had significantly increased risks of developing symptomatic intracerebral hemorrhage (adjusted OR, 14.7; 95% CI, 1.3 to 54.3). A trend for poorer stroke recovery and increased mortality was observed in warfarin-treated patients on univariate, but not on multivariable, analyses. Conclusions— Warfarin-treated patients with stroke have increased risks of symptomatic intracerebral hemorrhage after thrombolytic treatment. These data raise safety concerns of thrombolytic treatment in warfarin-treated patients with subtherapeutic international normalized ratio.

Background and Purpose— To evaluate the periprocedural outcome after carotid artery stenting with embolic brain protection (EBP+) versus without embolic brain protection (EBP−). Methods— We retrospectively reviewed data from a prospective nonrandomized database of 357 patients who underwent carotid artery stenting in the neuroradiology division of our institution from 1999 to 2009. One hundred five patients underwent angioplasty and stenting without distal protection, whereas 252 were treated with distal protection. Patients were analyzed according to their EBP status (+ or −) for the primary end points of perioperative stroke, death, or myocardial infarction. Results— Unprotected stenting was mostly performed in the early years of this study and this is reflected in significant baseline differences between the two groups. In our earlier experience, carotid artery stenting was used in patients with more significant comorbidities. Diabetes mellitus ( P =0.04), previous coronary artery disease ( P =0.02) and myocardial infarction ( P =0.04), and symptomatic lesion ( P =0.01) were significantly more common in the EBP− cohort. Despite these baseline differences, there were no significant differences in the primary end points (2% in the EBP+ group and 4.8% in the EBP−, P =0.15). The incidence of ipsilateral stroke in the EBP− and in the EBP+ group was 3.8% versus 0.8%, respectively ( P =0.6). There were 2 perioperative deaths (1 in each group) and 4 myocardial infarctions (3 in the EBP+ arm and 1 in the EBP− arm, all non-Q infarcts; P =nonsignificant). Conclusions— In accordance with recent literature, this series cast doubts as to the real effectiveness of distal embolic protection devices in reducing periprocedural complications.

Background and Purpose— Maturing techniques have spurred widespread implementation of endovascular embolectomy therapy for ischemic stroke. We evaluated a large administrative database to determine outcomes in patients treated with endovascular embolectomy in the general population. Methods— Using the National Inpatient Sample, we evaluated outcomes of patients treated for acute ischemic stroke in the United States from 2006 to 2008. Patients who had an ischemic stroke and underwent endovascular clot retrieval were identified. Morbidity, defined as “discharge to long-term facility,” and mortality were evaluated as a function of patient age and of concomitant thrombolytic agent administration. Results— For 2006 to 2008, a total of 3864 patients received endovascular clot retrieval with 266 (6.9%) patients in 2006, 800 (20.7) patients in 2007, and 2798 (72.4%) patients in 2008. The discharge to a long-term facility rate was 51.3% (1983 of 3864). The in-hospital mortality rate was 24.3% (940 of 3864). For patients <65 years old, the rate of in-hospital death was 17.1% (283 of 1658) as compared with a rate of 29.7% (656 of 2206) for patients ≥65 years old ( P <0.0001). The rate of discharge to a long-term facility was 47.6% (789 of 1658) for patients <65 years old and 54.1% (1193 of 2206) for patients ≥65 years old ( P <0.0001). The rate of intracranial hemorrhage was 15.5% without concomitant thrombolysis and 20.0% with concomitant thrombolysis ( P =0.0009). Conclusions— Rates of morbidity and mortality remain high for patients with acute stroke, even in the setting of endovascular embolectomy. Advanced age portends a worse outcome and patients treated with concomitant use of thrombolytic agent had higher rates of intracranial hemorrhage than those without such therapy.

Background and Purpose— Coronary artery disease is the leading cause of death after TIA. Reliable estimates of the risk of MI after TIA, however, are lacking. Methods— Our purpose was to determine the incidence of and risk factors for MI after TIA. We cross-referenced preexisting incidence cohorts from the Rochester Epidemiology Project for TIA (1985–1994) and MI (1979–2006) to identify all community residents with incident MI after incident TIA. Incidence of MI after TIA was determined using Kaplan–Meier life-table methods. This was compared to the age-, sex-, and period-specific MI incidences in the general population. Proportional hazards regression analysis was used to examine associations between clinical variables and the occurrence of MI after TIA. Results— Average annual incidence of MI after TIA was 0.95%. Relative risk for incident MI in the TIA cohort compared to the general population was 2.09 (95% CI, 1.52–2.81). This was highest in patients younger than 60 years old (relative risk, 15.1; 95% CI, 4.11–38.6). Increasing age (hazard ratio, 1.51 per 10 years; 95% CI, 1.14–2.01), male sex (hazard ratio, 2.19; 95% CI, 1.18–4.06), and the use of lipid-lowering therapy at the time of TIA (hazard ratio, 3.10; 95% CI, 1.20–8.00) were independent risk factors for MI after TIA. Conclusions— Average annual incidence of MI after TIA is ≈1%, approximately double that of the general population. The relative risk increase is especially high in patients younger than 60 years old. These data are useful for identifying subgroups of patients with TIA at highest risk for subsequent MI.

Background and Purpose— Age might differentially affect outcomes in patients treated for unruptured cerebral aneurysms with surgical clipping versus endovascular coil therapy. We evaluated a large administrative database to determine the effect of age on outcomes in patients treated for unruptured cerebral aneurysm. Methods— Using the National Inpatient Sample, we evaluated morbidity (discharge to long-term facility) and mortality of patients undergoing clipping or coiling of unruptured cerebral aneurysms in the United States between 2001 and 2008. Outcomes were evaluated in relation to four age strata: younger than 50 years; 50 to 64 years; 65 to 79 years; and patients 80 years or older. Results— Patients younger than 50 years old undergoing coiling had significantly lower morbidity rates when compared to patients who underwent clipping (3.5% versus 8.1%; P <0.0001), but no difference in mortality (0.6% versus 0.6%; P =0.72). Patients between 50 and 64 years old undergoing coiling had significantly decreased morbidity (4.0% versus 13.7%; P <0.0001) and mortality (0.5% versus 1.1%; P <0.0001) when compared to patients who underwent clipping. Coiled patients 65 to 79 years old had lower morbidity (6.9% versus 26.8%; P <0.0001) and mortality (0.8% versus 2.0%; P <0.0001) compared to patients who underwent clipping. Patients aged 80 years or older undergoing coiling also had lower morbidity (9.8% versus 33.5%; P <0.0001) and mortality (2.4% versus 21.4%; P <0.0001) when compared to patients who have undergone clipping. Conclusions— Patients treated with endovascular coiling have significantly less morbidity and mortality than those treated with surgical clipping, and these differences become more pronounced with age.

Background and Purpose— The purpose of this study was to determine and compare the rate of stroke, myocardial infarction, and death in patients undergoing early and late carotid endarterectomy (CEA) after a symptomatic event and in asymptomatic patients. Methods— We conducted a retrospective analysis of all CEAs performed in the Department of Neurosurgery between January 2004 and May 2009. Patients were divided into 3 groups: Group 1, asymptomatic patients; Group 2, symptomatic patients operated on >2 weeks after their transient ischemic attack or stroke; and Group 3, symptomatic patients operated on ≤2 weeks of their transient ischemic attack or stroke. Primary outcomes were any myocardial infarction, stroke, or death occurring within 30 days postoperatively. The secondary end point was transient ischemic attack within 30 days postoperatively. Results— Five hundred thirty-two CEAs were performed on 507 patients during the study period. Thirty-day follow-up was available for 500 patients with 525 CEAs. Groups 1, 2, and 3 consisted of 278, 105, and 142 CEAs, respectively. In total, 12 patients had primary outcomes. In Group 1, 5 patients had primary outcomes of stroke, myocardial infarction, or death (1.8%); in Group 2, 1 patient had primary outcomes (1.0%); and in Group 3, 6 patients had primary outcomes (4.2%). There was no significant difference in the rate of primary outcomes among the 3 groups ( P =0.17) or when Groups 2 and 3 were compared ( P =0.24). Conclusions— Although the perioperative risk of transient ischemic attacks, stroke, death, and myocardial infarction is slightly higher in symptomatic patients operated on early, CEA can be done with an acceptable risk in properly selected symptomatic patients within 2 weeks of their transient ischemic attack or stroke.