Background and Purpose-Increased sympathetic drive after stroke is involved in the pathophysiology of several complications including poststroke immunudepression. β-Blocker (BB) therapy has been suggested to have neuroprotective properties and to decrease infectious complications after stroke. We aimed to examine the effects of random pre-and onstroke BB exposure on mortality, functional outcome, and occurrence of pneumonia after ischemic stroke. Methods-Data including standard demographic and clinical variables as well as prestroke and on-stroke antihypertensive medication, incidence of pneumonia, functional outcome defined using modified Rankin Scale and mortality at 3 months were extracted from the Virtual International Stroke Trials Archive. For statistical analysis multivariable Poisson regression was used. Results-In total, 5212 patients were analyzed. A total of 1155 (22.2%) patients were treated with BB before stroke onset and 244 (4.7%) patients were newly started with BB in the acute phase of stroke. Mortality was 17.5%, favorable outcome (defined as modified Rankin Scale, 0-2) occurred in 58.2% and pneumonia in 8.2% of patients. Prestroke BB showed no association with mortality. On-stroke BB was associated with reduced mortality (adjusted risk ratio, 0.63; 95% confidence interval, 0.42-0.96). Neither prestroke BB nor on-stroke BB showed an association with functional outcome. Both prestroke and on-stroke BB were associated with reduced frequency of pneumonia (adjusted risk ratio, 0.77; 95% confidence interval, 0.6-0.98 and risk ratio, 0.49; 95% confidence interval, 0.25-0.95). Conclusions-In this large nonrandomized comparison, on-stroke BB was associated with reduced mortality. Prestroke and on-stroke BB were inversely associated with incidence of nosocomial pneumonia. Randomized trials investigating the potential of β-blockade in acute stroke may be warranted.

Conclusions: Thoracic endovascular aortic repair (TEVAR) is a safe and effective treatment for thoracic aortic aneurysms. TEVAR provides improved perioperative results and similar long-term results as open thoracic aortic repair. TEVAR-treated aneurysms initially decrease in diameter and then stabilize over time.Summary: Early clinical results with TEVAR have generally shown a trend toward better perioperative survival and less major perioperative complications than open thoracic aortic aneurysm repair. The early results of the pivotal trials used to gain approval of the Gore TAG, Medtronic Talent, and Cook Zenith TX2 stent grafts provided highly favorable midterm data for stent grafts. Longer-term data are still desirable, however. The authors investigated long-term survival and freedom from aortic complications in patients enrolled in five U.S. Food and Drug Administration investigational device exemption studies of TEVAR grafts from a single center and compared them with a group of open control patients with similar anatomic features. Demographic, clinical, and radiographic parameters were collected prospectively from patients enrolled in trials assessing the Gore TAG ( 55), Medtronic Talent (36), and Cook TX2 (15) devices. Outcomes in patients treated with these stent grafts were compared with 45 contemporaneous open controls. From 1995 to 2007, there were 106 patients enrolled in TEVAR trials at the hospital of the University of Pennsylvania and 45 open controls. TEVAR patients were older and had more comorbidities, including diabetes and renal failure. TEVAR patients had 2.3 Ϯ 1.3 devices implanted. Mortality (2.6% TEVAR, 6.7% open; P ϭ .1) and paralysis/ paraparesis (3.9% TEAVR, 7.1% open; P ϭ .2) did not differ in the open vs TEVAR patients. Prolonged intubation Ͼ24 hours was more common in the open controls (9% TEVAR, 24% open; P ϭ .002). Overall survival at 8 to 10 years was ϳ40% and was similar between groups (log-rank P ϭ .5). Predictors of late mortality included age, diabetes, chronic renal failure, and chronic obstructive coronary disease. Use of TEVAR vs open surgery did not influence mortality (hazard ratio, 0.9; 95% confidence interval, 0.4-1.6). At 5 years in the TEVAR group, mean aortic diameter decreased from 61 to 55 mm. Freedom from reintervention of the treated segment was 85% in TEVAR patients at 10 years.Comment: The article highlights the fact that compared with the number of patients in whom TEVAR has been performed, the number of patients with long term follow-up is still relatively small. (The University of Pennsylvania group has reported Ͼ500 TEVAR procedures in other articles.) In the discussion after the article, Dr Craig Miller from Stanford indicates that he is concerned that "the entire thoracic field is being 'dumbed down' as the TEVAR era evolved." One can easily extrapolate Dr Miller's concerned to all endovascular techniques "dumbing down" all of vascular surgery. In the long run, however, outcomes rather than nostalgia will drive practice patterns in the treatment of vascu...

The summed Alberta Stroke Program Early CT Score (ASPECTS) is useful for predicting stroke outcome. The anatomical information in the CT template is rarely used for this purpose because traditional regression methods are not adept at handling collinearity (relatedness) among brain regions. While penalized logistic regression (PLR) can handle collinearity, it does not provide an intuitive understanding of the interaction among network structures in a way that eigenvector method such as PageRank can (used in Google search engine). In this exploratory analysis we applied graph theoretical analysis to explore the relationship among ASPECTS regions with respect to disability outcome. The Virtual International Stroke Trials Archive (VISTA) was searched for patients who had infarct in at least one ASPECTS region (ASPECTS ≤9, ASPECTS=10 were excluded), and disability (modified Rankin score/mRS). A directed graph was created from a cross correlation matrix (thresholded at false discovery rate of 0.01) of the ASPECTS regions and demographic variables and disability (mRS>2). We estimated the network-based importance of each ASPECTS region by comparing PageRank and node strength measures. These results were compared with those from PLR. There were 185 subjects, average age 67.5± 12.8 years (55% Males). Model 1: demographic variables having no direct connection with disability, the highest PageRank was M2 (0.225, bootstrap 95% CI 0.215-0.347). Model 2: demographic variables having direct connection with disability, the highest PageRank were M2 (0.205, bootstrap 95% CI 0.194-0.367) and M5 (0.125, bootstrap 95% CI 0.096-0.204). Both models illustrate the importance of M2 region to disability. The PageRank method reveals complex interaction among ASPECTS regions with respects to disability. This approach may help to understand the infarcted brain network involved in stroke disability.

Background and Purpose— National Institutes of Health Stroke Scale (NIHSS) item profiles that were recently proposed may prove useful both clinically and for research studies. We aimed to validate the NIHSS item profiles in an acute cohort. Methods— We conducted a retrospective analysis on pooled data from randomized clinical trials. We applied the latent class analysis probabilities of profile membership developed from the derivation study to obtain symptom grouping, a -NIHSS item profiles. We implemented an independent latent class analysis to derive secondary symptom grouping, b -NIHSS item profiles. Validation was performed by assessing the associations with outcomes and evaluating both sets of NIHSS item profiles’ discrimination and calibration to the data. The outcomes evaluated included modified Rankin Scale (mRS; using the full distribution and dichotomized, mRS, 0–1) at day 90 and mortality by 90 days. Results— We identified 10 271 patients. Ordinal analysis of mRS confirmed increased odds of better outcome across the profiles in a stepwise manner, adjusted for age and thrombolysis treatment, for each set of NIHSS item profiles. Similar patterns were observed for mRS 0 to 1, and inverse patterns were seen for mortality. The c -statistics of a -NIHSS and b -NIHSS item profiles for mRS 0 to 1 were similar at 0.71 (95% confidence interval, 0.70–0.72) and for mortality, 0.74 (0.73–0.75) and 0.75 (0.73–0.76), respectively. Calibration was good. Conclusions— These NIHSS item profiles identified using latent class analysis offer a reliable approach to capture the true response patterns that are associated with functional and outcome and mortality post stroke. This approach has the potential to enhance the clinical value of the overall NIHSS score.

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