Journal of Clinical Medicine

Research

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20 pages, 707 KiB

Open AccessArticle

Racial Impact on Inpatient Stroke Quality of Care in Two Community Hospitals

by Haitham M. Hussein, Mai-Kau Yang, Solmaz Ramezani, Rishi Sharma, Omair ul haq Lodhi, Yaroslav Owens-Pochinka, Jinci Lu and Ahmed Elbokl

J. Clin. Med. 2023, 12(24), 7654; https://doi.org/10.3390/jcm12247654 - 13 Dec 2023

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Abstract

Introduction: This analysis was conducted as a part of a quality improvement project aiming at identifying racial disparity in inpatient stroke quality of care. Methods: The Get With The Guidelines (GWTG) database was used to identify all patients discharged with any stroke diagnosis [...] Read more.

Introduction: This analysis was conducted as a part of a quality improvement project aiming at identifying racial disparity in inpatient stroke quality of care. Methods: The Get With The Guidelines (GWTG) database was used to identify all patients discharged with any stroke diagnosis between January and December 2021. An additional chart review was conducted to ensure the accuracy of racial/ethnic categorization. The sample was dichotomized into white vs. non-white groups and compared with univariate analysis. Results: The study sample comprised 1408 encounters (1347 patients) with Mean age of 71 ± 15 years, 51% women, 82% white patients, 15% non-white patients, 72% acute ischemic stroke (AIS); 15% transient ischemic attack (TIA), 9% intracerebral hemorrhage (ICH), 3% subarachnoid hemorrhage (SAH), and 1% stroke not otherwise specified. Non-white patients were younger and had fewer concomitant diagnoses, a lower proportion of TIA, and a higher proportion of ICH (p = 0.004). In the AIS cohort, compared to white patients, non-white patients had less frequent ambulance (p = 0.009), arrived at the hospital later than white patients (7.7 h longer; p < 0.001), had more severe strokes, and had less frequent IV thrombolysis utilization (7% vs. 13%; p = 0.042). Similarly, in the TIA cohort, non-white patients’ utilization of EMS was lower than that of white patients, and their hospital arrival was delayed. In the ICH cohort, non-white patients were younger and had a lower frequency of atrial fibrillation and a non-significant trend toward higher disease severity. The SAH cohort had only eight non-white patients, six of whom were transferred to a higher level of hospital care within a few hours of arrival. Importantly, the hospital-based quality metrics, such as door-to-CT time, door-to-needle time, and the Joint Commission stroke quality metrics, were similar between the two groups. Conclusions: There is a racial disparity in the pre-hospital phase of the stroke chain of survival of non-white patients, impacting IV thrombolysis utilization. The younger age and worse lipid profile and hemoglobin A1c of non-white patients suggest the need for better preventative care starting at a young age. Full article

(This article belongs to the Special Issue Ischemic Stroke, with Latest on Diagnosis to Treatment and Recovery)

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11 pages, 1229 KiB

Open AccessArticle

Diffusion Restriction in the Splenium: A Comparative Study of Cytotoxic Lesions of the Corpus Callosum (CLOCCs) versus Lesions of Vascular Etiology

by Brian Stamm, Christina M. Lineback, Mengxuan Tang, Dan Tong Jia, Ella Chrenka, Farzaneh A. Sorond and Behnam Sabayan

J. Clin. Med. 2023, 12(22), 6979; https://doi.org/10.3390/jcm12226979 - 8 Nov 2023

Viewed by 851

Abstract

Cytotoxic lesions of the corpus callosum (CLOCCs) have broad differential diagnoses. Differentiating these lesions from lesions of vascular etiology is of high clinical significance. We compared the clinical and radiological characteristics and outcomes between vascular splenial lesions and CLOCCs in a retrospective cohort [...] Read more.

Cytotoxic lesions of the corpus callosum (CLOCCs) have broad differential diagnoses. Differentiating these lesions from lesions of vascular etiology is of high clinical significance. We compared the clinical and radiological characteristics and outcomes between vascular splenial lesions and CLOCCs in a retrospective cohort study. We examined the clinical and radiologic characteristics and outcomes in 155 patients with diffusion restriction in the splenium of the corpus callosum. Patients with lesions attributed to a vascular etiology (N = 124) were older (64.1 vs. 34.6 years old, p < 0.001) and had >1 vascular risk factor (91.1% vs. 45.2%, p < 0.001), higher LDL and A1c levels, and echocardiographic abnormalities (all p ≤ 0.05). CLOCCs (N = 31) more commonly had midline splenial involvement (p < 0.001) with only splenial diffusion restriction (p < 0.001), whereas vascular etiology lesions were more likely to have multifocal areas of diffusion restriction (p = 0.002). The rate of in-hospital mortality was significantly higher in patients with vascular etiology lesions (p = 0.04). Across vascular etiology lesions, cardio-embolism was the most frequent stroke mechanism (29.8%). Our study shows that corpus callosum diffusion restricted lesions of vascular etiology and CLOCCs are associated with different baseline, clinical, and radiological characteristics and outcomes. Accurately differentiating these lesions is important for appropriate treatment and secondary prevention. Full article

(This article belongs to the Special Issue Ischemic Stroke, with Latest on Diagnosis to Treatment and Recovery)

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Review

Jump to: Research

16 pages, 1097 KiB

Open AccessReview

The Impact of Anti-Amyloid Immunotherapies on Stroke Care

by Philippe A. Bilodeau, John R. Dickson and Mariel G. Kozberg

J. Clin. Med. 2024, 13(5), 1245; https://doi.org/10.3390/jcm13051245 - 22 Feb 2024

Cited by 1 | Viewed by 1370

Abstract

Anti-amyloid immunotherapies have recently emerged as treatments for Alzheimer’s disease. While these therapies have demonstrated efficacy in clearing amyloid-β and slowing cognitive decline, they have also been associated with amyloid-related imaging abnormalities (ARIA) which include both edema (ARIA-E) and hemorrhage (ARIA-H). Given that [...] Read more.

Anti-amyloid immunotherapies have recently emerged as treatments for Alzheimer’s disease. While these therapies have demonstrated efficacy in clearing amyloid-β and slowing cognitive decline, they have also been associated with amyloid-related imaging abnormalities (ARIA) which include both edema (ARIA-E) and hemorrhage (ARIA-H). Given that ARIA have been associated with significant morbidity in cases of antithrombotic or thrombolytic therapy, an understanding of mechanisms of and risk factors for ARIA is of critical importance for stroke care. We discuss the latest data regarding mechanisms of ARIA, including the role of underlying cerebral amyloid angiopathy, and implications for ischemic stroke prevention and management. Full article

(This article belongs to the Special Issue Ischemic Stroke, with Latest on Diagnosis to Treatment and Recovery)

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28 pages, 980 KiB

Open AccessReview

Post-Stroke Brain Health Monitoring and Optimization: A Narrative Review

by Eric L. Stulberg, Perminder S. Sachdev, Anne M. Murray, Steven C. Cramer, Farzaneh A. Sorond, Kamakshi Lakshminarayan and Behnam Sabayan

J. Clin. Med. 2023, 12(23), 7413; https://doi.org/10.3390/jcm12237413 - 29 Nov 2023

Viewed by 1801

Abstract

Significant advancements have been made in recent years in the acute treatment and secondary prevention of stroke. However, a large proportion of stroke survivors will go on to have enduring physical, cognitive, and psychological disabilities from suboptimal post-stroke brain health. Impaired brain health [...] Read more.

Significant advancements have been made in recent years in the acute treatment and secondary prevention of stroke. However, a large proportion of stroke survivors will go on to have enduring physical, cognitive, and psychological disabilities from suboptimal post-stroke brain health. Impaired brain health following stroke thus warrants increased attention from clinicians and researchers alike. In this narrative review based on an open timeframe search of the PubMed, Scopus, and Web of Science databases, we define post-stroke brain health and appraise the body of research focused on modifiable vascular, lifestyle, and psychosocial factors for optimizing post-stroke brain health. In addition, we make clinical recommendations for the monitoring and management of post-stroke brain health at major post-stroke transition points centered on four key intertwined domains: cognition, psychosocial health, physical functioning, and global vascular health. Finally, we discuss potential future work in the field of post-stroke brain health, including the use of remote monitoring and interventions, neuromodulation, multi-morbidity interventions, enriched environments, and the need to address inequities in post-stroke brain health. As post-stroke brain health is a relatively new, rapidly evolving, and broad clinical and research field, this narrative review aims to identify and summarize the evidence base to help clinicians and researchers tailor their own approach to integrating post-stroke brain health into their practices. Full article

(This article belongs to the Special Issue Ischemic Stroke, with Latest on Diagnosis to Treatment and Recovery)

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19 pages, 682 KiB

Open AccessReview

Advances in Stroke Neurorehabilitation

by Muhammed Enes Gunduz, Bilal Bucak and Zafer Keser

J. Clin. Med. 2023, 12(21), 6734; https://doi.org/10.3390/jcm12216734 - 25 Oct 2023

Cited by 1 | Viewed by 2938

Abstract

Stroke is one of the leading causes of disability worldwide despite recent advances in hyperacute interventions to lessen the initial impact of stroke. Stroke recovery therapies are crucial in reducing the long-term disability burden after stroke. Stroke recovery treatment options have rapidly expanded [...] Read more.

Stroke is one of the leading causes of disability worldwide despite recent advances in hyperacute interventions to lessen the initial impact of stroke. Stroke recovery therapies are crucial in reducing the long-term disability burden after stroke. Stroke recovery treatment options have rapidly expanded within the last decade, and we are in the dawn of an exciting era of multimodal therapeutic approaches to improve post-stroke recovery. In this narrative review, we highlighted various promising advances in treatment and technologies targeting stroke rehabilitation, including activity-based therapies, non-invasive and minimally invasive brain stimulation techniques, robotics-assisted therapies, brain–computer interfaces, pharmacological treatments, and cognitive therapies. These new therapies are targeted to enhance neural plasticity as well as provide an adequate dose of rehabilitation and improve adherence and participation. Novel activity-based therapies and telerehabilitation are promising tools to improve accessibility and provide adequate dosing. Multidisciplinary treatment models are crucial for post-stroke neurorehabilitation, and further adjuvant treatments with brain stimulation techniques and pharmacological agents should be considered to maximize the recovery. Among many challenges in the field, the heterogeneity of patients included in the study and the mixed methodologies and results across small-scale studies are the cardinal ones. Biomarker-driven individualized approaches will move the field forward, and so will large-scale clinical trials with a well-targeted patient population. Full article

(This article belongs to the Special Issue Ischemic Stroke, with Latest on Diagnosis to Treatment and Recovery)

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26 pages, 1622 KiB

Open AccessReview

Evolving Clinical–Translational Investigations of Cerebroprotection in Ischemic Stroke

by Yinghui Li, Laurel E. Schappell, Claire Polizu, James DiPersio, Stella E. Tsirka, Marc W. Halterman and Neil A. Nadkarni

J. Clin. Med. 2023, 12(21), 6715; https://doi.org/10.3390/jcm12216715 - 24 Oct 2023

Cited by 1 | Viewed by 1313

Abstract

Ischemic stroke is a highly morbid disease, with over 50% of large vessel stroke (middle cerebral artery or internal carotid artery terminus occlusion) patients suffering disability despite maximal acute reperfusion therapy with thrombolysis and thrombectomy. The discovery of the ischemic penumbra in the [...] Read more.

Ischemic stroke is a highly morbid disease, with over 50% of large vessel stroke (middle cerebral artery or internal carotid artery terminus occlusion) patients suffering disability despite maximal acute reperfusion therapy with thrombolysis and thrombectomy. The discovery of the ischemic penumbra in the 1980s laid the foundation for a salvageable territory in ischemic stroke. Since then, the concept of neuroprotection has been a focus of post-stroke care to (1) minimize the conversion from penumbra to core irreversible infarct, (2) limit secondary damage from ischemia-reperfusion injury, inflammation, and excitotoxicity and (3) to encourage tissue repair. However, despite multiple studies, the preclinical–clinical research enterprise has not yet created an agent that mitigates post-stroke outcomes beyond thrombolysis and mechanical clot retrieval. These translational gaps have not deterred the scientific community as agents are under continuous investigation. The NIH has recently promoted the concept of cerebroprotection to consider the whole brain post-stroke rather than just the neurons. This review will briefly outline the translational science of past, current, and emerging breakthroughs in cerebroprotection and use of these foundational ideas to develop a novel paradigm for optimizing stroke outcomes. Full article

(This article belongs to the Special Issue Ischemic Stroke, with Latest on Diagnosis to Treatment and Recovery)

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27 pages, 388 KiB

Open AccessReview

Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke

by Ibrahim Migdady, Phoebe H. Johnson-Black, Thabele Leslie-Mazwi and Rishi Malhotra

J. Clin. Med. 2023, 12(20), 6641; https://doi.org/10.3390/jcm12206641 - 20 Oct 2023

Cited by 1 | Viewed by 1559

Abstract

The volume of infarcted tissue in patients with ischemic stroke is consistently associated with increased morbidity and mortality. Initial studies of endovascular thrombectomy for large-vessel occlusion excluded patients with established large-core infarcts, even when large volumes of salvageable brain tissue were present, due [...] Read more.

The volume of infarcted tissue in patients with ischemic stroke is consistently associated with increased morbidity and mortality. Initial studies of endovascular thrombectomy for large-vessel occlusion excluded patients with established large-core infarcts, even when large volumes of salvageable brain tissue were present, due to the high risk of hemorrhagic transformation and reperfusion injury. However, recent retrospective and prospective studies have shown improved outcomes with endovascular thrombectomy, and several clinical trials were recently published to evaluate the efficacy of endovascular management of patients presenting with large-core infarcts. With or without thrombectomy, patients with large-core infarcts remain at high risk of in-hospital complications such as hemorrhagic transformation, malignant cerebral edema, seizures, and others. Expert neurocritical care management is necessary to optimize blood pressure control, mitigate secondary brain injury, manage cerebral edema and elevated intracranial pressure, and implement various neuroprotective measures. Herein, we present an overview of the current and emerging evidence pertaining to endovascular treatment for large-core infarcts, recent advances in neurocritical care strategies, and their impact on optimizing patient outcomes. Full article

(This article belongs to the Special Issue Ischemic Stroke, with Latest on Diagnosis to Treatment and Recovery)

16 pages, 2230 KiB

Open AccessReview

Contrast-Enhanced Ultrasound Feasibility in Assessing Carotid Plaque Vulnerability—Narrative Review

by Ewa Kopyto, Marcin Czeczelewski, Eryk Mikos, Karol Stępniak, Maja Kopyto, Małgorzata Matuszek, Karolina Nieoczym, Adam Czarnecki, Maryla Kuczyńska, Mateusz Cheda, Anna Drelich-Zbroja and Tomasz Jargiełło

J. Clin. Med. 2023, 12(19), 6416; https://doi.org/10.3390/jcm12196416 - 9 Oct 2023

Cited by 2 | Viewed by 1362

Abstract

The risk assessment for carotid atherosclerotic lesions involves not only determining the degree of stenosis but also plaque morphology and its composition. Recently, carotid contrast-enhanced ultrasound (CEUS) has gained importance for evaluating vulnerable plaques. This review explores CEUS’s utility in detecting carotid plaque [...] Read more.

The risk assessment for carotid atherosclerotic lesions involves not only determining the degree of stenosis but also plaque morphology and its composition. Recently, carotid contrast-enhanced ultrasound (CEUS) has gained importance for evaluating vulnerable plaques. This review explores CEUS’s utility in detecting carotid plaque surface irregularities and ulcerations as well as intraplaque neovascularization and its alignment with histology. Initial indications suggest that CEUS might have the potential to anticipate cerebrovascular incidents. Nevertheless, there is a need for extensive, multicenter prospective studies that explore the relationships between CEUS observations and patient clinical outcomes in cases of carotid atherosclerotic disease. Full article

(This article belongs to the Special Issue Ischemic Stroke, with Latest on Diagnosis to Treatment and Recovery)

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