Thrombolysis in acute ischemic stroke in patients with dementia

Županič, Eva; Euler, Mia von; Kåreholt, Ingemar; Escamez, Beatriz Contreras; Fastbom, Johan; Norrving, Bo; Religa, Dorota; Kramberger, Milica G.; Winblad, Bengt; Johnell, Kristina; Eriksdotter, Maria; García-Ptacek, Sara

doi:10.1212/wnl.0000000000004598

Cited by 33 publications

(38 citation statements)

References 22 publications

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“…We found that acute reperfusion treatment was less utilized in patients with ischemic stroke who had a history of psychosis. A lower likelihood of reperfusion treatment was also found in patients with pre-stroke dementia in a recent analysis of thrombolysis in Swedish patients (21). However, this difference disappeared when adjusting for pre-stroke functional status.…”

Section: Discussionmentioning

confidence: 69%

The Association of Pre-stroke Psychosis and Post-stroke Levels of Health, Resource Utilization, and Care Process: A Register-Based Study

et al. 2018

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Background: While approximately one percent of the global population is formally diagnosed with psychosis or schizophrenia, the actual number is expected to be significantly higher. These patients often consume more healthcare resources and have poorer somatic health. In this study, we analyze potential differences in health, resources, and care process between stroke patients with and without a previous diagnosis of psychosis or schizophrenia.Methods: Ischemic stroke patients from seven regions in Sweden were identified via ICD-10 codes (I63.0-9) in regional administrative systems and the Swedish Stroke Register, and approximately 70% of all ischemic stroke cases in Sweden during 2008–2011 were included (n = 46,350). Relevant patient-level data from national registries were linked to enable multivariate regression analysis, including data on socioeconomics, mortality, municipality services, and filled prescriptions. History of psychosis or schizophrenia was defined via ICD-10 codes F20-29 (n = 389).Results: Patient-reported functional outcomes at 3 months and 1 year were significantly lower in the psychosis subgroup, and stroke recurrence was higher. Patients with pre-stroke psychosis did not receive the same levels of reperfusion treatment as the non-psychosis group. Time at the stroke unit was the same, as were first-year levels of somatic care, but dispensation of antihypertensives was less common.Conclusion: Our findings emphasize the importance of taking mental comorbidity into account during stroke treatment as well as when evaluating indicators for health, resources, and the care process, since mental comorbidity such as psychosis or schizophrenia may have a significant impact the year preceding and the year succeeding the stroke event.

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Section: Discussionmentioning

confidence: 69%

The Association of Pre-stroke Psychosis and Post-stroke Levels of Health, Resource Utilization, and Care Process: A Register-Based Study

et al. 2018

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“…While there are few data on thrombectomy in these patients, observational studies of thrombolysis in patients with dementia suggest that mortality and hemorrhage risks are comparable to those without dementia, though functional outcomes may be worse. [22][23][24] In this regard, it is noteworthy that most respondents chose alteplase in the scenario with MCI.…”

Section: Discussionmentioning

confidence: 98%

Endovascular Therapy or Alteplase in Patients with Comorbidities: Insights from UNMASK EVT

Ganesh

Kashani

Ospel

et al. 2020

Can. J. Neurol. Sci.

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Objective: Decisions to treat large-vessel occlusion with endovascular therapy (EVT) or intravenous alteplase depend on how physicians weigh benefits against risks when considering patients’ comorbidities. We explored EVT/alteplase decision-making by stroke experts in the setting of comorbidity/disability. Methods: In an international multi-disciplinary survey, experts chose treatment approaches under current resources and under assumed ideal conditions for 10 of 22 randomly assigned case scenarios. Five included comorbidities (cancer, cardiac/respiratory/renal disease, mild cognitive impairment [MCI], physical dependence). We examined scenario/respondent characteristics associated with EVT/alteplase decisions using multivariable logistic regressions. Results: Among 607 physicians (38 countries), EVT was chosen less often in comorbidity-related scenarios (79.6% under current resources, 82.7% assuming ideal conditions) versus six “level-1A” scenarios for which EVT/alteplase was clearly indicated by current guidelines (91.1% and 95.1%, respectively, odds ratio [OR] [current resources]: 0.38, 95% confidence interval 0.31–0.47). However, EVT was chosen more often in comorbidity-related scenarios compared to all other 17 scenarios (79.6% versus 74.4% under current resources, OR: 1.34, 1.17–1.54). Responses favoring alteplase for comorbidity-related scenarios (e.g. 75.0% under current resources) were comparable to level-1A scenarios (72.2%) and higher than all others (60.4%). No comorbidity independently diminished EVT odds when considering all scenarios. MCI and dependence carried higher alteplase odds; cancer and cardiac/respiratory/renal disease had lower odds. Being older/female carried lower EVT odds. Relevant respondent characteristics included performing more EVT cases/year (higher EVT-, lower alteplase odds), practicing in East Asia (higher EVT odds), and in interventional neuroradiology (lower alteplase odds vs neurology). Conclusion: Moderate-to-severe comorbidities did not consistently deter experts from EVT, suggesting equipoise about withholding EVT based on comorbidities. However, alteplase was often foregone when respondents chose EVT. Differences in decision-making by patient age/sex merit further study.

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“…A greater understanding of the differences and similarities between males and females with respect to previous cardiovascular risk factors [1, 17, 18, 20], previous physical or mental condition [21, 22], response to acute stroke therapies, and recovery will hopefully lead to better outcomes in the future.…”

Section: Discussionmentioning

confidence: 99%

Long-Term Survival After Stroke According to Reperfusion Therapy, Cardiovascular Therapy and Gender

et al. 2019

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Background A wide variety of factors influence stroke prognosis, including age, stroke severity and comorbid conditions; but most current information about outcomes and safety is derived from patients at 3 - 12 months and mostly coming from the hospital activity. The aim of this study is to evaluate whether treatment strategies have a differential impact on long-survival after acute ischemic stroke among men versus women. Methods Acute ischemic stroke patients identified from the population-based register between January 1, 2011 and December 31, 2012 were included, and they were classified into: 1) Acute ischemic stroke + intravenous thrombolysis (group I); 2) Acute ischemic stroke + mechanical thrombectomy with or without intravenous thrombolysis (group II); 3) Acute ischemic stroke + medical therapy alone (no reperfusion therapies) (group III). Follow-up went through up until December 2016. The probability of survival was estimated by the Kaplan-Meier method, and the hazard ratio was obtained by using the Cox proportional hazard regression models. Mortality was interpreted as overall mortality. Results A total of 14,368 cases (men 50.1%), 77.1 ± 11.0 years old were included. There was higher survival among those treated with intravenous thrombolysis (P < 0.001); women treated with thrombectomy (P < 0.001); and women < 80 years old without reperfusion therapy. The most common medications were antiplatelets (52.8%), associated with lower survival (P < 0.001); and statins (46.5%), associated with higher survival. The regression model produced the following independent outcome variables associated to mortality: anticoagulant hazard ratio (HR) 1.53 (95% confidence interval (95% CI): 1.44 - 1.63, P < 0.001), diuretics HR 1.71 (95% CI: 1.63 - 1.79, P < 0.001), antiplatelet HR 1.49 (95% CI: 1.42 - 1.56, P < 0.001), statins HR 0.73 (95% CI: 0.70 - 0.77; P < 0.001), angiotensin II receptor antagonists HR 0.93 (95% CI: 0.89 - 0.98, P = 0.008) and reperfusion therapy HR 0.88 (95% CI: 0.81 - 0.97, P = 0.009). Conclusions Men and women have different prognoses after revascularization treatment for acute ischemic stroke. Under 80 years old the women appear to have a better outcome than men when treated with thrombolysis therapy and/or catheter-based thrombectomy. The chronic cardiovascular pharmacotherapy must be evaluated whether they should be included as factors in the decision to reperfusion.

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Thrombolysis in acute ischemic stroke in patients with dementia

Cited by 33 publications

References 22 publications

The Association of Pre-stroke Psychosis and Post-stroke Levels of Health, Resource Utilization, and Care Process: A Register-Based Study

The Association of Pre-stroke Psychosis and Post-stroke Levels of Health, Resource Utilization, and Care Process: A Register-Based Study

Endovascular Therapy or Alteplase in Patients with Comorbidities: Insights from UNMASK EVT

Long-Term Survival After Stroke According to Reperfusion Therapy, Cardiovascular Therapy and Gender

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